PRACTICAL TREATISE 



SEXUAL DISORDERS 



MALE AND FEMALE. 



BY 

ROBERT W. TAYLOR, A.M., M.D., 

CLINICAL PROFESSOR OF VENEREAL DISEASES AT THE COLLEGE OF PHYSICIANS AND SURGEONS 
(COLUMBIA UNIVERSITY), NEW YORK ; SURGEON TO BELLEVUE HOSPITAL, AND CON- 
SULTING SURGEON TO THE CITY (CHARITY) HOSPITAL, NEW YORK. 



SECOND EDITION, THOROUGHLY REVISED. 



WITH 91 ILLUSTRATIONS AND 13 PLATES IN COLOR AND MONOCHROME. 




LEA BROTHERS & CO., 

NEW YORK AND PHILADELPHIA. 

1900. 



TWO COPICS RICE1VSD, 

Library of Congee* 
Office., tk \ * 

MAY 24 1900 

Hegl.ter of Copyrlg» u 



9* 

SECOND COPY. 



^ <2 9> /?<*> 






6*713 

Entered according to the Act of Congress, in the year 1900, by 

LEA BKOTHEKS & CO., 

In the Office of the Librarian of Congress, at Washington. All rights reserved. 



DORNAN, PRINTER. 



/ 






TO 



GEOKGB L. PEABODY, A.M., M.D., 

PROFESSOR OF MATERIA MEDICA AND THERAPEUTICS AT THE COLLEGE 

OF PHYSICIANS AND SURGEONS (COLUMBIA 

UNIVERSITY), NEW YORK, 

THIS WORK 
IS CORDIALLY DEDICATED 



THE AUTHOK. 



PREFACE TO SECOND EDITION, 



The very gratifying reception accorded to the first edition of 
this work has prompted me to make every effort to render the 
second edition still more acceptable to the profession. To this 
end I have carefully gone over the whole text, and have revised, 
amplified, added to, and in places modified it. 

The subject of sexual disorders in women has been more 
thoroughly treated, and entirely new chapters have been written 
on vaginismus, masturbation in women, and kraurosis vulvae. 

The chapters on the anatomy and physiology of the sexual 
apparatus and on psychical impotence and masturbation in male 
subjects have been rewritten and very much enlarged. 

In addition, many new sections and interpolations have 
been added, notably those on enlargement of the dorsal veins 
of the penis as a cause of impotence, on syphilitic oedema of 
the penis, tuberculosis of the prostate, and tuberculosis of the 
seminal vesicles. 

Much attention has been paid to the matter of therapeutics in 
the direction of clearness of statement and of practicality. Many 
new illustrations in color and monochrome will be found in 
this edition, the majority of which are original. 

It is therefore hoped that this work will continue to merit 
the favor of practitioners as a guide to the study and treatment 
of this important class of diseases. 

Robert W. Taylor. 



40 West Twenty-first Street, New York. 
May, 1900. 



CONTENTS 



CHAPTEE I. 

PAGE 

INTRODUCTION 17 



CHAPTER IT. 

ANATOMY AND PHYSIOLOGY OF THE SEXUAL APPARATUS —THE PENIS, 
THE URETHRA, THE BLADDER, THE PROSTATE, THE SEMINAL VESICLES 
AND ACCESSORY PARTS. 

The corpora cavernosa — Nerves of the penis — The integument of 
the penis — The prepuce — The meatus — The compressor urethra? 
muscle — The bulbous urethra— The penile urethra — Mucous 
secretion and the follicles and glands of the urethra — The pros- 
tate gland and the prostatic urethra — The seminal vesicles — The 
ampullations of the vasa deferentia and the ejaculatory ducts — 
The intrinsic and extrinsic muscles of the sexual apparatus — The 
testes and the vasa deferentia 20-55 



CHAPTER III. 

THE PHYSIOLOGY OF THE MALE SEXUAL FUNCTION. 

The mechanism of erection — The mechanism of ejaculation . 56-60 
CHAPTER IV. 

NATURE AND COMPOSITION OF THE SEMINAL FLUID. 

The semen — The secretion of the seminal vesicles — The secretion of 
the prostate gland— The secretion of Littre's follicles, of the 
crypts of Morgagni, and of Cowper's glands . . . 61-75 



viii CONTENTS. 

CHAPTER V. 



PAGE 

IMPOTENCE IN THE MALE . ... 76 

CHAPTER VI. 

PSYCHICAL IMPOTENCE .... 78 



CHAPTER VII. 

SYMPTOMATIC IMPOTENCE. 

Peripheral irritation — Chronic bulbous urethritis and stricture — 
Chronic bulbous and posterior urethritis— Chronic bulbous and 
posterior urethritis with prostatitis — Chronic posterior urethritis 
— Chronic prostatitis — Inflammation of the seminal vesicles 88-97 

CHAPTER VIII. 

ATONIC IMPOTENCE 98 

CHAPTER IX. 

ORGANIC IMPOTENCE 105 

CHAPTER X. 

ORGANIC IMPOTENCE FROM CONGENITAL DEFECTS AND MALFORMATIONS 
OF THE PENIS AND VARICOSITY OF ITS DORSAL VEINS. 

Absence of the penis — Hypospadias and epispadias, and torsion of the 
penis — Abnormalities in the size of the penis — Double penis — 
Enlargement of the dorsal veins of the penis . . . 106-118 

CHAPTER Xr. 

ORGANIC IMPOTENCE FROM DESTRUCTION OF THE INTEGUMENT OF THE 
PENIS, AND FROM BENIGN AND MALIGNANT NEW-GROWTHS AND 
PREPUTIAL CALCULI. 

Destructive lesions of the integument of the penis — Chancroidal 
ulceration — Phagedena in syphilis — Gangrene of the penis — 
Traumatism— Vegetations of the penis — Horny growths of the 
penis — Elephantiasis of the penis — Cancer of the penis — Indu- 
rating oedema of the penis — Preputial calculi . . . 119-136 



CONTENTS. ix 

CHAPTER XII. 

PAGE 
ORGANIC IMPOTENCE DUE TO DEGENERATIVE, HYPERPLASTIC AND TRAU- 
MATIC CHANGES IN THE CORPORA CAVERNOSA. 

Ossification of the penis — Fibroid sclerosis of the corpora cavernosa — 
Syphilitic nodes in the corpora cavernosa and corpus spongiosum 
— Curvature of the penis — Fracture of the penis . . . 137-152 

CHAPTER XIII. 

STERILITY IN THE MALE .... 153 

CHAPTER XIV. 

AZOOSPERMATISM. 

Ectopia testis — Changes in the epididymis, testis, and vas deferens, 
due to gonorrhoea— Gonorrheal epididymitis — Gonorrheal orchi- 
tis— Gonorrheal funiculitis, or deferentitis — Changes in the 
epididymis, testis, and vas deferens, due to syphilis — Syphilitic 
epididymitis — Syphilitic orchitis — Syphilitic funiculitis, or defer- 
entitis — Hereditary syphilis of the testis — Chronic orchitis and 
epididymitis — Orchitis and epididymo-orchitis, due to general 
infective processes — Mump orchitis — Tonsillar orchitis — Variola 
orchitis — Scarlatina orchitis — Malarial orchitis — Grip orchitis — 
Orchitis due to muscular effort — Strangulation of the testis and 
epididymis from torsion of the cord— Hydrocele — Hematocele — 
Tuberculosis of the testis — Tuberculosis of the prostate — Tuber- 
culosis of the seminal vesicles — Atrophy of the testis . . 155-185 

CHAPTER XV. 

AZOOSPERMATISM DUE TO ABNORMAL CONDITIONS OP THE SEMEN. 

The effects of repeated and excessive coitus — Influence of the prostatic 
secretion — Pus-admixture — Blood-admixture — Bloody ej acula- 
tions — The influence of general morbid conditions — Watery semen 
and colloid semen — Diminished quantity of semen . . 186-196 

CHAPTER XVI. 

ASPERMATISM. 

Lesions of the seminal vesicles and deferential ampullations — Lesions 
of the ejaculatory ducts — Stricture of the urethra and urethral 
calculi — Anomalous cases of aspermatism — Mutilating meatotomy 
and damage to the urethra — Partial aspermatism — Debility and 
lack of nerve force 197-207 



x CONTENTS. 

CHAPTER XVII. 

PAGE 
CHRONIC INFLAMMATION OF THE BULBOUS AND PROSTATIC URETHRA, 
STENOSIS AND STRICTURES. 

Chronic inflammation of the bulbous urethra — Chronic posterior 
urethritis — Treatment of stenosis and strictures of the bulbous 
urethra 208-228 

CHAPTER XVIII. 

CHRONIC AFFECTIONS OF THE PROSTATE. 

Gonorrheal congestion of the prostate — Chronic inflammation of the 
verumontanum and prostatic urethra — Chronic catarrhal inflam- 
mation of the prostate —Catarrhal prostatitis in young subjects — 
Catarrhal prostatitis in older subjects— Prostatorrhcea— Hyper- 
trophy of the prostate 229-263 

CHAPTER XIX. 

INFLAMMATION OF THE SEMINAL VESICLES. 

Chronic seminal vesiculitis — More advanced form of seminal vesic- 
ulitis 264-277 

CHAPTER XX. 

VARICOCELE 278 

CHAPTER XXI. 

MASTURBATION IN MALE SUBJECTS. . . . 286 

CHAPTER XXII. 

SEXUAL EXCESSES AND SEXUAL ERETHISM. 

Sexual erethism 297-302 

CHAPTER XXIII. 

SPERMATORRHEA. 

Imaginary spermatorrhoea 303-308 

CHAPTER XXIV. 

SEXUAL WORRY AND HYPOCHONDRIASIS AND SEXUAL NEURASTHENIA. 

Sexual worry — Sexual hypochondriasis — Sexual neurasthenia . 309-322 



CONTENTS. xi 

CHAPTER XXV. 

PAGE 
COITUS RESERVATUS VEL 1NTERRUPTUS ; WITHDRAWAL, OB, CONJU- 
GAL ONANISM 323 

CHAPTER XXVI. 

PRIAPISM. 

Priapism after spinal injury — Priapism in cerebral and descending 
spinal disease — Priapism due to sexual and alcoholic excess — 
Priapism of leuksemic origin (?) 333-342 

CHAPTER XXVII. 

SEXUAL PERVERSION 343 

CHAPTER XXVIII. 

STERILITY IN THE FEMALE .... 346 

CHAPTER XXIX. 

VAGINISMUS 351 

CHAPTER XXX. 

MASTURBATION IN THE FEMALE .... 357 

CHAPTER XXXI. 

NEW GROWTHS AND HYPERTROPHIES OF THE VULVA WHICH MAY 

LEAD TO STERILITY 366 

CHAPTER XXXII. 

VEGETATIONS OF THE VULVA. 

Vulvar hypertrophy consequent upon vegetations — Hyperplastic 

growths of the vulva — Urethral caruncles .... 369-377 

CHAPTER XXXIII. 

LARGE HYPERTROPHIES OF THE VULVA . . . 378- 



xii CONTENTS. 

CHAPTER XXXIV. 

PAGE 
INFILTRATION AND DISTORTION OF THE VULVA FROM CHRONIC 

CHANCROIDS 388 

CHAPTER XXXV. 

HYPERTROPHIES OF THE VULVA DUE TO SYPHILIS. 

Condylomata — Vulvar deformities in the early and late stages of 
syphilis due to indurating oedema — Chronic chancroids in old 
syphilitics — Distortion of the vulva in old syphilitics — Distortion 
of the vulva with destructive ulceration .... 394-405 

CHAPTER XXXVI. 

TUBERCULOUS ULCERS OF THE VULVA . . . 406 

CHAPTER XXXVII. 

A PECULIAR NEW GROWTH OF THE VULVA . . 408 

CHAPTER XXXVIII. 

KRAUROSIS VULVAE 422 



SEXUAL DISORDERS 

OF THE 

MALE AND THE FEMALE 



CHAPTER I. 

INTRODUCTION. 



It certainly can be stated, without fear of contradiction, that 
until recently the subject of sexual disorders had been treated in 
books and essays in a loose and impracticable manner. This condi- 
tion was due to the facts that the study of these affections was not 
thoroughly entered into and that the necessary groundwork of 
pathological anatomy had been entirely neglected. It thus came 
to pass that works on these subjects were unsatisfactory, unscien- 
tific, and largely based on unsound and visionary theories, and that 
clearly stated scientific facts were not advanced. Unwarranted 
and theoretical assumptions were indulged in and no real progress 
was attained. In looking over the various treatises one is struck 
with the entire absence of definite and rational statement and 
argument and the utter want of proper therapeutic deductions 
and indications. Heretofore the whole basis of medical knowl- 
edge of sexual disorders might be summed up in the recital of 
various ill-defined symptoms, such as sexual debility and irrita- 
bility, seminal losses, spermatorrhoea, pollutions, and functional 
disturbances and sensory and motor neuroses of .the genital system 
in the male. It can be readily understood that no author can 
approach toward doing justice to the study of sexual disorders 
who allows himself to be fettered and trammelled by the study 
and elaboration of this unscientific conglomeration of symptoms. 

2 



18 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

The trend of thought and study of sexual and genito-urinary 
diseases among some authors within the last few years has been 
in the direction of acquirng knowledge of the intimate structure 
and functions of the various portions of the urinary and sexual 
apparatus and of the nature and course of the various morbid 
processes which attack this highly important system, and it is 
gratifying to be able to state that much useful information has 
been gained. This spirit has dominated the writer in the prepa- 
ration of the present volume ; and while by classic custom it has 
become an author's duty to treat of the various forms of sexual 
debility prominently as symptoms, the underlying anatomical and 
physiological conditions have never been lost sight of, and the 
light of pathology has been thrown on the picture as fully as our 
present experience will warrant. 

The endeavor has been made to fully describe the anatomy and 
physiology of the whole sexual apparatus in a scientific and philo- 
sophical manner, and in so doing the results of extended personal 
investigations have been incorporated. The importance of urethral 
inflammations as an underlying cause of sexual impairment has 
been duly emphasized. Much care has been bestowed on the 
description of chronic affections of the prostate (an organ, when 
damaged, so often the cause of sexual debility), and in this chapter 
there is much that is new which has been developed by the inves- 
tigations of the author. The conditions of the seminal vesicles 
and their relation, when diseased, to sexual disorders have been 
fully elaborated, and much information based on personal inves- 
tigation is here given. In fact, the basis of the study of genito- 
urinary diseases will be found in this book. But so vast and 
intricate is the field of sexual disorders that more is required of 
a man who wishes to thoroughly understand the subject than has 
thus far been mentioned. 

In the first place, well-grounded knowledge of physiology and 
of general medicine and a general understanding of the anatomy, 
physiology, and pathology of the nervous system are absolutely 
necessary. And, in addition, the surgeon needs a clear under- 
standing of the nature and course of syphilis, of the pathology 



INTRODUCTION. 19 

of gonorrhoeal infection, and of all acute and chronic infective 
processes. And, still further to this long list of requirements, the 
knowledge of the use of the microscope in the examination of the 
urine and of the various secretions of the body is absolutely essen- 
tial. When studied on these broad lines diseases which in former 
years were vaguely if at all understood, and even shunned by 
medical men, can now be discussed on scientific and practical 
grounds, and whereas heretofore treatment was largely haphazard 
and empirical, and, as a rule, without benefit to the patient, to-day 
it can be entered upon on a scientific and satisfactory basis. 

The subject of sterility in women is considered in a general 
manner with the idea of conveying to the mind of the reader the 
conditions which tend to render a woman unfertile. The various 
forms of sexual disorders in women are also quite fully considered. 



CHAPTER II. 

ANATOMY AND PHYSIOLOGY OF THE SEXUAL APPARATUS 
—THE PENIS, THE URETHRA, THE BLADDER, THE PROS- 
TATE, THE SEMINAL VESICLES AND ACCESSORY PARTS. 

The penis is a pendulous organ consisting of root, body, and 
glans, and through it three-fourths of the urethra runs. It is 
the organ of copulation and of urination, and is composed of two 
parallel cylindrical bodies called the corpora cavernosa, which, 
lying side by side, have a groove on their under surface in which 
is situated the corpus spongiosum. These cylindrical bodies, with 
connective tissues, vessels, nerves, and lymphatics, together with 
the tegumentary investment sheath, form the penis. (See Plate 
I., Fig. 1.) 

THE CORPORA CAVERNOSA. 

Each corpus caver nosum has a dense, quite, thick, but very 
elastic fibrous investment, from which thin processes or trabecule 
pass inwardly and form cavities, which are filled with erectile 
tissue. The inner surface of each cavernous body is thick and 
complete in the proximal part of the penis ; consequently, there 
is at that part a distinct septum formed by the fusion of these 
two inner surfaces. More anteriorly or distally there are only a 
number of vertical bands of fibrous tissue arranged like the teeth 
of a comb, and hence called the septum pectiniforme. It is im- 
portant to bear in mind the structure and relations of the cavernous 
bodies, as well as of the spongy body, in operations on the penile 
urethra. The corpus spongiosum also consists of a firm, fibrous 
sheath, from which trabecular processes pass inward and form 
meshes which contain erectile tissue. In the outer coat of the 
corpus spongiosum is a thin layer of circular muscular fibres con- 
tinuous with those of the bladder. A second layer of longitudinal 



PLATE I 



FIG 1. 




Transverse Section of the Penis. 

Showing Corpora Cavernosa, Corpus Spongiosum and Urethra, with 
Musculature of the Parts. 



FIG. 2. 



CAVERNOUS 
BRANCH 




INTERNAL PU DIC^;, **/? 



Arteries of the Penis. (Testut.) 



ANATOMY. 21 

muscular fibres is situated between the inner surface of the corpus 
spongiosum and the mucous membrane of the urethra. 

The corpora cavernosa constitute the chief bulk of the penis, 
and each one begins in a tapering portion, the erus penis, which is 
attached along a groove in the rami of the ischium and os pubis. 
They are further attached to the symphysis pubis by a strong, 
elastic suspensory ligament, the base of which is fused in their 
fibrous tissue, and the apex is inserted into the symphysis. Con- 
verging together at once at the root of the penis, these cylindrical 
bodies run parallel side by side, and each ends in a bluntly rounded 
extremity which fits in a depression in the base of the glans 
penis. 

The Corpus Spongiosum. The corpus spongiosum surrounds 
the urethra from the triangular ligament to the meatus urinarius. 
It begins in the centre of the perineum in an expanded form 
called the bulb, which rests directly on the anterior surface of the 
triangular ligament. It then runs under the corpora cavernosa 
in the groove left for it, like a ramrod under a double-barrelled 
gun, and ends in an expanded extremity — the glans penis, the 
apex of which corresponds to the meatus. 

The glans penis is, therefore, the expanded distal portion of the 
corpus spongiosum, while the bulb is its proximal expanded por- 
tion. The glans is an obtusely conical, acorn-shaped body, some- 
what flattened on its upper surface, and ending in a rounded, 
expanded portion called the corona, which rounds off abruptly 
and projects like a collar beyond the body of the penis proper, 
and behind it is seen, when the prepuce is retracted, a nearly cir- 
cular groove called the coronal sulcus, the balano-preputial fur- 
row, and the cervix. A little below the centre of the apex is 
the vertical slit-like opening of the urethra, called the meatus. 

The under surface of the glans is flat and triangular in shape, 
the apex of which usually ends in the inferior commissure of the 
meatus, and into it the frsenum of the prepuce is inserted. 

The arteries of the penis are derived from the external pudic 
and from the superficial perineal and the dorsal artery of the penis, 
which are branches of the external pudic. (See Plate I., Fig. 2.) 



22 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

The veins of the penis converge from the prepuce and the three 
cavernous bodies and begin as a common canal at its dorsum, called 
the superficial dorsal vein. (See Plate II.) 

Nerves of the Penis. 

There are different classes of nerves in the penis concerned in 
erection and ejaculation. Those of the first order are the sensory 
nerves, which are most abundant in the glans penis ; but they are 
also present in the integument of the organ, and transmit irrita- 
tions, stimulation, and impressions backward to the sexual centre. 
In the second order, anatomically speaking, but more important, 
perhaps, in a physiological sense, are the excitor nerves. 

These nerves, called the nervi erigentes, or excitor nerves, are 
derived from the first and second and sometimes from the third 
sacral nerves. It is thought that these nerves originate in the 
sexual centre, which is supposed to be seated in the lumbosacral 
portion of the spinal column. Experiments on animals have 
shown that stimulation of these nerves causes erection of the 
penis, which is, therefore, essentially due to the vasodilator action 
upon the arterioles. 

The facts are well established that in the human subject mental 
impressions are transmitted down the spinal cord, probably in its 
lateral columns, to the sexual centre, which undergoes excitation, 
which is thereupon further transmitted through the nervi erigentes 
to the penis and accessory parts of the sexual apparatus. Periph- 
eral excitation of the sensory nerves in the glans penis and penis 
itself is conducted back by them to the spinal sexual centre, which, 
in turn, by reflex action through the nervi erigentes, acts upon the 
sexual sphere and induces erection. 

Certain facts derived from experimental physiology, and sup- 
ported by clinical observation, go to show that it is probable that 
besides the excitor nerves there are inhibitory nerves of erection 
which originate in the brain and pass down the lateral columns of 
the cord to the sexual centre. As will be shown in subsequent 
sections, erection may be materially modified or extinguished by 



PLATE II. 




IAL DORSAL VEIN 
EXTERNAL PUDIC VEIN 

URATOR VEIN 



Veins of the Penis. (Testut.) 



ANATOMY. 23 

mental impressions, and it is very probable that this restraining 
effect is due to these inhibitory nerves. 

In the glans penis the nerve-supply is peculiarly exuberant, 
and many of the nerves end in Pacinian bodies, while others 
have at their ends peculiar bulb-like expansions. This rich 
nerve-supply also exists in and about the frsenum, and it is to it 
that the excessive sensitiveness of these parts is due. 

The foregoing facts certainly warrant the opinion that the sen- 
sorium commune of the external male genitals is seated in the 
glans penis, which includes in its territory the regions of the 
frsenum and of the fossa navicularis. 

It is claimed by some that at the bulb of the urethra the nerve- 
supply resembles that of the glans. Certain it is, that in this 
region the blood-supply is particularly copious. The integument 
of the penis, the scrotum, and urethra are also abundantly sup- 
plied by nerves. 

As might be expected from the structure and function of the 
corpora cavernosa and corpus spongiosum, these parts are freely 
supplied by fibres of the sympathetic nerves which are derived 
from the pelvic or inferior hypogastric plexus. It is claimed by 
some investigators that the entire sympathetic nerve-supply goes 
to these erectile bodies. 

In the consideration of the nerve-supply to the penis particular 
attention should be paid to the verumontanum. In this structure, 
composed of mucous membrane, erectile tissue, and muscular tissue 
richly supplied by bloodvessels, the nerve-supply is particularly 
abundant ; hence, this part is usually exquisitely sensitive, is the 
seat of the pleasurable sensations in coitus, and in disease becomes 
a factor of much importance and gravity. 

It will be thus seen that while there is an external sensorium 
commune of the sexual apparatus, seated at the distal part of the 
penis, there is also an internal sensorium, seated in the middle of 
the prostatic urethra. 



24 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

The Integument of the Penis. 

The integument of the penis forms an investing sheath which 
retains its tubular form in the normal condition up to a little 
beyond the extremity of the glans penis. Then it is reflected or 
folds on itself backward, in the form of a mucous membrane, and 
is inserted by gradual merging into the whole length of the cor- 
onal sulcus. It is then reflected forward over the glans, to which 
it is firmly adherent, and ends at or a little within the orifice of 
the meatus, with the mucous membrane of which it is continuous. 
Thus it is that for a short distance (one-quarter to one inch or 
more) the mucous membrane of the urethra consists of squamous 
or pavement epithelium. 

That portion of the under surface of the prepuce which is in 
the median line becomes transformed into a fibrous band, which is 
called the frsenum preputii, and which, as we have seen, is in- 
serted just under the lower part of the meatus urinarius. The 
prepuce, therefore, consists of two layers — the outer one integu- 
mentary and continuous with the skin of the penis, and the inner 
or reflected one formed of mucous membrane, which is covered 
with stratified pavement epithelium, which extends, as already 
stated, into the meatus for a varying distance. 

The integument of the penis is very thin and extensible, and 
very readily movable over the cavernous and spongy bodies by 
means of a very delicate, loose, and abundant connective tissue 
destitute of fat-cells. 

The integument of the penis is plentifully supplied with seba- 
ceous and hair-follicles, which frequently become the seat of in- 
flammatory processes and of new growths (milia and wens). 

The Prepuce. 

In the normal condition the prepuce, or foreskin, forms a tube 
of quite uniform calibre, which is loose and roomy and readily 
admits of its retraction and replacement over the glans penis. 
Usually it ends at or just beyond the meatus. In some cases, 
however, it is redundant and extends more or less beyond the end 



ANATOMY. 25 

of the penis. Then, again, it may be short, so as only to cover 
a portion of the glans, and in quite exceptional cases in the adult 
there is no prepuce at all. In this event it has happened that as 
the penis developed the integumentary layer did not correspond- 
ingly increase. 

Sometimes the preputial orifice is very small, so that it will 
with difficulty allow the glans to emerge through it. Then, 
again, this contraction may be so great that only a pin-sized 
aperture is seen, in which event retraction is impossible, and 
very little of the glans or meatus can be seen. In some cases 
the calibre of the prepuce is decidedly too small for its easy 
retraction, and it then may exert injurious pressure upon the 
glans. In other cases the frsenum is too short (and it is then 
usually a rather thick cord), and by the contraction which it 
exerts upon the prepuce some deformity results. 

The penis is cylindrical when flaccid, triangular in shape when 
turgid, and therefore has three sides, with corresponding rounded 
margins. The dorsal flat surface is broader than the lateral sur- 
faces are. 

The Glandular Structure of the Prepuce. It is widely stated 
that the mucous layer of the prepuce normally contains minute 
sebaceous glands called by old writers glandulce Tysonii odoriferce. 
This, however, is erroneous. Whenever present, Tyson's glands 
are situated externally on the penis, and are distributed along the 
corona glandis in the sulcus and on the reflection of the prepuce 
and near the frsenum. In young children these glands are fairly 
numerous, but in adults they are much more difficult to find, as 
they seem to become atrophied to a large extent. Tyson's glands 
are identical in every respect in structure to the sebaceous glands 
of the skin or scalp. They consist of two or more bag-like acini 
lying just beneath the epidermis, which open into a common duct, 
and the whole cellular lining of the duct and the gland is con- 
tinuous with the epithelium of the skin. (See Fig. 1.) 

Recent observations show that the preputial mucous membrane, 
as a rule, contains no glandular structures whatever, but that there 
are minute inversions or invaginations of the mucous membrane 



26 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

in the form of diverticula, aud longer and narrower ones found 
near the frrenum, which are called cysternse frsenuli. The so- 
called glands are therefore simply reduplicatures or invaginations 
of the membrane in the form of minute shallow or deep crypts. 

Certain clinical and pathological observations, however, seem 
to show that occasionally one or more Tyson's glands persist in 

later life. 

Fig. 1. 




Showing a section (much magnified) through one of Tyson's glands in the 
prepuce of a young child. ( Drawn from nature. ) 

Preputial smegma, that whitish coating of cheesy odor, is there- 
fore simply effete epithelium, perhaps formed in the crypts or on 
the mucous membrane itself. 



The Meatus. 

The meatus is normally a constricted part of the urethra. In 
structure it varies more or less in different individuals. In some 
its vertical lips are thin and coapt with each other like the leaves 
of a book, forming a not prominent vertical slit. In other cases 
the lips are more or less rounded and the meatus has a rather 
expanded, pouting appearance. Then, again, owing to the fact 



ANATOMY. 27 

that the mucous membrane is rather redundant and loose, its lips 
sometimes have an uneven, somewhat mammillated appearance. 
In some very rare cases the mucous membrane forms a cylinder 
of a line, or even a third of an inch, in length beyond the apex 
of the glans, constituting a membranous extension of the urethra. 
In somewhat rare cases a thin septum is seen to extend horizon- 
tally across from one lip to the other, seemingly dividing the 
meatus into two parts. Separation of the lips, however, shows 
that this septum simply forms a blind pocket which may be shallow 
or rather deep. In this condition the narrowing of the meatus is 
at its superior portion, and therefore the surgical indication here 
is to relieve the trouble by cutting toward the roof of the urethra, 
while in almost all other cases the rule is to cut toward its floor. 

In somewhat exceptional cases the meatus is very small, even 
of pin-head size. In this case it will generally be found, by pass- 
ing the tip of a probe inward and downward, that the abnormal 
smallness of the calibre is due to the fusion of the mucous mem- 
brane at the lower commissure. 

The Male Urethra. The male urethra is a slit-like canal, 
regarded by some as a closed valve, which extends from the 
bladder to the meatus urinarius. It is the vent-pipe for the 
urine and gives issue to the seminal fluid. It therefore has two 
functions, which must be kept in mind in order that its diseases 
may be clearly understood. It is in direct relation with the kid- 
neys, the ureters, and the bladder, and may be the means of trans- 
mitting disease to these organs of the urinary system, or it, in turn, 
may become diseased by the extension of pathological processes 
from these organs and structures. Then, again, pathological pro- 
cesses attacking the urethra may extend to all or to certain portions 
of the genital system — namely, the testicles, the vasa deferentia, 
the seminal vesicles, and the prostate and its crypts and follicles. 
In its turn the urethra may be involved by the extension of dis- 
ease from either of these structures and appendages, with which 
it is in direct anatomical relation. If the function of the urethra 
were simply that of transmitting the urine, a length of about two 
inches would be sufficient, as it is in the female, but, being also a 



28 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

part of the genital apparatus, its length is necessarily much in- 
creased for purposes of intromission and fecundation of the female. 
This increase in length, as we have seen, is due to the existence 
of the cavernous and spongy bodies. 

The urethra is composed of three layers — a mucous layer, a 
submucous connective tissue layer, and a muscular layer. Its 
walls are always in contact, except during the passage of urine 
and semen, a period of three or four minutes during the day. 
The average length of the urethra is from seven to eight and a 
half inches, but it may be shorter or longer. It is increased in 
length during erection and in hypertrophy of the prostate. 

When the urethra is split longitudinally in its whole extent on 
its upper surface, its course, with its varying expansions, comes 
into view. (See Fig. 2.) At the meatus urinarius we find a nor- 
mal narrowing of the canal, which then expands into a spindle- 
shaped portion, which is called the fossa navicularis ; hence this 
is called the navicular portion of the urethra. As this part 
emerges into the spongy or penile portion a slight constriction 
occurs. The canal then expands, and we find it of somewhat 
uniform calibre in its course through the corpus spongiosum for 
a distance of four or five inches. It then expands again, in con- 
formity with the bulbous expansion of the corpus spongiosum, 
and a spindle-shaped canal is formed, which is from an inch to 
an inch and a half in length, and which is called the sinus of the 
bulb or the bulbous portion of the urethra. Again becoming con- 
tracted at the anterior layer of the triangular ligament, it has a 
uniform calibre for a distance of about three-quarters of an inch, 
when, at the posterior layer of this ligament, it emerges to expand 
again into the prostatic urethra. In its course through the trian- 
gular ligament it is simply a membranous canal seated about an 
inch beneath the summit of the pubic arch and surrounded by the 
compressor urethrse muscle. The prostatic urethra is the direct 
continuation of the membranous urethra. It also has a spindle 
shape, and is about an inch and a quarter in length. (See Fig. 
2.) Thus, anatomically, there is a navicular, a spongy, a bulbous, 
a membranous, and a prostatic portion of the urethra, making five 



ANATOMY. 



29 



divisions in all. The term 
" penile," or pendulous, 
urethra is also applied to 
that portion which extends 
from the glans to the peno- 
scrotal angle. 

Clinically, in a general 
way, we speak of the ante- 
rior and posterior urethra, 
the former extending to the 
anterior layer of the trian- 
gular ligament, and the lat- 
ter including the portion 
beyond. 

The mucous membrane of 
the urethra, is smooth and 
shining and of a yellowish- 
pink color, which is deeper 
at the first inch and at the 
bulbous portion. For a 
short distance — one-fourth 
to one inch within the me- 
atus — the membrane is cov- 
ered with flat pavement epi- 
thelium ; beyond that part 
it is of the columnar variety 
as far as the vesical orifice. 

Course of the Urethra. 
The direction of the pros- 
tatic urethra, which is in a 

fixed position, is downward 

j £ t , .i ., i Showing the normal urethra opened longi- 

and torward until it reaches s . „ . * A^ * 

tudmally on its upper surface. ( Drawn from 

the posterior layer of the na ture. ) 

triangular ligament, when it 

becomes the membranous urethra, which pursues nearly the same 

direction, with a slightly upward tendency. 




30 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

The membranous urethra is from three-quarters to an inch in 
length and of a calibre of 27 F., and, owing to the fact that this 
segment of the canal forms a part of the subpubic curve of the 
urethra, its superior wall is somewhat shorter than the inferior 
wall. It is peculiar in the fact that it is composed wholly of 
mucous membrane, with a submucous connective tissue coat and 
some unstriped muscular fibres. It is the least vascular part of 
the urethral canal, and has very few mucous glands and crypts. 
By reason of its anatomical structure it is not so severely affected 
by the gonorrheal process as the other portions are ; consequently, 
it is rarely, if ever, the seat of true stricture except from exten- 
sion of the process from the bulbous urethra. 

The membranous urethra is situated and held in a fixed position 
between the two layers of the triangular ligament — a knowledge 
which is essential. 

The Triangular Ligament. The triangular ligament, which is 
a portion of deep perineal fascia, consists of two layers — an ante- 
rior and a posterior layer — between which is the compressor ure- 
thras muscle. The anterior layer is a dense, fibrous membrane 
stretching from the posterior lip of the os pubis and ischium. 
This anterior layer is about an inch and a half in length, and, in 
accord with the direction of the pubic bone, its base is directed 
backward. About an inch below the symphysis pubis is the 
urethral orifice, the external termination of the membranous 
urethra. The triangular ligament extends upward toward the 
symphysis to a distance just above the hole for the urethra, 
and above that is the dense, fibrous tissue called "Henle's 
deep transverse ligament of the pelvis," which is pierced by 
the openings for the vessels and nerves. The triangular liga- 
ment and Henle's ligament, therefore, close this part of the 
pelvic outlet. 

The posterior layer of the triangular ligament is derived from 
the obturator fascia, and from it a prolongation passes backward 
and forms the outer capsule of the prostate. Its upper portion, 
called Henle's ligament, is pierced by the opening for the plexus 
venoms pubicus impar, which consists of veins returning from the 



PLATE III. 




Showing the Compressor Urethrse or Cut-off Muscle. 



ANATOMY. 31 

penis and of the dorsal arteries. The triangular ligament proper 
is pierced by the membranous urethra. 

The Compressor Urethrae Muscle. 

When the anterior layer of the triangular ligament is dissected 
off the compressor urethrae muscle is exposed in the form of a 
firm, flat muscular band, rather more than an inch wide, stretched 
between the pubic rami, but not wholly covering the pelvic outlet 
at its apex. (See Plate III.) This muscle, also called the con- 
strictor urethrae, the cut-off muscle, is composed of transverse 
fibres of the striped variety, some of which pass directly over and 
some under the urethra, while others pass around and encircle it. 
This muscle is very powerful, and, being under the control of the 
will, it can at any time suddenly stop the flow of urine. Though 
the external prostatic sphincter consists of rings of unstriped 
muscular fibres at the apex of the prostate, the greater part of the 
true sphincteric action is performed by the compressor muscle. 
In the course of acute and chronic gonorrhoea, and during irrita- 
tive processes in the prostate, seminal vesicles, and bladder, this 
muscle may undergo spasm and produce what is wrongly termed 
" spasmodic stricture." Under the influence of rough manipula- 
tion by instruments in the urethra, of cold, and of very strong and 
irritating urethral injections, spasm may also be produced. Then, 
again, as a result of operations about the rectum, abdomen, lower 
limbs, etc., this muscle may be thrown into spasm, and retention of 
urine may result. Some authors claim that this muscle is always 
in a state of rigid contraction, or tonus, so that the lumen of the 
urethra is of the fineness of a hair, and that this contraction tends 
to prevent the extension of the gonorrheal process from the ante- 
rior into the posterior urethra, and also acts as a dam, preventing 
the secretions in the prostatic and membranous urethra escaping 
into the anterior urethra. This is far too sweeping a statement. 
When the bladder is more or less full the compressor or constrictor 
urethrae closes up the membranous urethra and prevents the escape 
of urine ; but when the bladder is not full, even in cases of sub- 
acute inflammation in any part of the urethra, bulbous or prostatic, 



32 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

there is not in the majority of cases any unusual tonus or spasm 
of this muscle. This fact can be readily demonstrated, as I have 
done hundreds of times, by the gentle passage into the bladder of 
a soft catheter or bougie of a calibre of 12 or 14 French. This 
instrument, causing no irritation or nervous shock, glides easily 
first into the membranous urethra, then along the prostatic urethra 
into the bladder. The excessive tonus claimed to be peculiar to 
this muscle in general occurs when rigid instruments, particularly 
of large size and when not skilfully passed, are used, or when in- 
jections have been forcibly made. Then the nerves of the urethra 
are disturbed and prompt reflex spasm of the muscle occurs. In 
the majority of persons the compressor muscle and the external 
prostatic sphincter keep the urethral canal mildly compressed — 
that is, its tonicity is such that the lumen of the canal is obliter- 
ated by the coaptation of the folds of membrane, but there is no 
spasm. Consequently, it occurs, as a rule, that the secretions of 
the prostatic urethra are kept from escaping into the anterior 
urethra. Though this may be stated as the law, it has exceptions 
in some cases of acute posterior urethritis, in some of prostator- 
rhoea, and in some of suppuration of the seminal vesicles. 

On each side of the membranous urethra, quite near to it and 
seated in the substance of the compressor muscle, are Cowper's 
glands. (See Fig. 3.) 

The Bulbous Urethra. 

Lying just upon the anterior layer of the triangular ligament 
is the bulb of the corpus spongiosum, containing the bulbous ex- 
pansion of the urethra. Here the membranous urethra ends, and 
the part is called the bulbo-membranous junction. The urethra 
enters the bulbous expansion nearer its upper than its lower half ; 
consequently the pouch-like dilatation of the urethra is greater 
on its lower surface. It is this condition which sometimes causes 
trouble in the passage of sounds and catheters, to obviate which 
it is necessary to keep the point of the instrument toward the roof 
of the urethra, and to put the penis on stretch in order to efface 
the pouchy pocket as much as possible. 



ANATOMY. 



33 



The bulbous portion of the urethra or the sinus of the bulb is 
unusually vascular, and its tissues are soft and succulent. Con- 
sequently, the gonorrheal process is often very acute and severe 
at this part, and the disease shows a tendency here to remain in a 
chronic condition. As a result, we find the larger number of true 
strictures in this region. 

The direction of the bulbous urethra is forward and upward, 
and its calibre is from 33 to 36 French. The downward and for- 
ward direction of the prostatic urethra and the slightly upward 

Fig. 3. 




Showing the normal contractions and expansions of the urethra from the 
meatus to the bladder, with a Cowper's gland opening by its duct into the bulbous 
urethra. (Schematic from nature. ) 

direction of the membranous urethra, with the decidedly upward 
direction of the bulbous urethra, form what is called the subpubic 
curve. 

The Penile Urethra. 

Continuous outwardly with the bulbous portion of the urethra 
is the spongy penile or pendulous urethra. It, like the bulbous 
portion, is contained in the corpus spongiosum. It is from six 
to six and a half inches (sometimes more) in length, and is sur- 
rounded by erectile tissue. The mucous membrane crypts and 
follicles of this portion of the urethra will be described a little 

3 



34 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

further on. The calibre of the penile or pendulous urethra is 
usually from 27 to 30 French, but it is often found to be greater 
than this measurement. The penile urethra is susceptible of con- 
siderable clilatability, but it must be remembered that the word 
" calibre " represents normal distention, such as is found by the 
moderately easy passage of instruments or by the stream of urine, 
while " dilatability " means a calibre produced by unusual or ex- 
cessive distention of the canal by instruments. 

The distal portion of the urethra seated in the glans penis is 
called the fossa navicularis or the navicular portion of the urethra. 
It is of spindle shape, and at its middle portion its calibre is 30 
to 33 F. At its point of junction with the penile urethra the 
calibre is from about 28 to 30 F. The calibre of the meatus, 
the terminal point of the urethra externally, is from 21 to 28 F. ; 
exceptionally, however, it is greater. A schematic representation 
of the urethra with its normal contractions and expansions is given 
in Fig. 3. 

The degree of mobility of different portions of the urethra is 
chiefly influenced by the attachments of the neighboring fasciae. 
The anterior part of the penis is free, and capable, in a flaccid 
condition, of assuming almost any position ; in its posterior third, 
however, this organ is connected with the symphysis by means of 
the suspensory ligament, with the ischiatic and pubic rami by the 
crura of the corpora cavernosa, and with the anterior layer of the 
triangular ligament by means of the bulb ; the spongy urethra 
may, therefore, be said to be fixed in proportion as it approaches 
the membranous region. The membranous region is the least 
movable of all, owing to its firm connection with the pelvis by 
means of the two layers of the triangular ligament. The pros- 
tatic urethra is susceptible of some slight change of position, de- 
pendent upon the action of the anterior fibres of the levator ani, 
the amount of urine in the bladder, and the passage of sounds or 
catheters. 

In a flaccid condition of the penis the urethra has two curves 
— the first confined to the anterior, the second to the deepest 
portion of the canal. The former is simply due to the dependent 



ANATOMY. 35 

position of the anterior part of the organ, and is effaced in a state 
of erection or when the penis is elevated to an angle of about 60° 
with the body. The latter is called the subpubic curve, from its 
position beneath the symphysis. Unless some degree of force be 
used to straighten the canal this curve is permanent, and a knowl- 
edge of its direction is essential in determining the proper form 
of instruments and the manner of their introduction. 

The subpubic curve commences an inch and a half anterior to 
the bulb in the penile urethra, attains its lowest point when the 
body is in the upright position nearly opposite the anterior layer 
of the triangular ligament, and finally ascends through the mem- 
branous and prostatic regions. 

MUCOUS SECRETION AND THE FOLLICLES AND 
GLANDS OF THE URETHRA. 

In healthy individuals in moments of sexual excitement a 
few or many drops of a clear and mucous secretion escape from 
the meatus. In some forms of sexual ill-health the secretion may 
become much more abundant than normal, and both in health 
and in ill-health it is sometimes the cause of much mental anxiety. 
It is necessary, therefore, to understand clearly the nature and 
origin of this mucous secretion. 

Into the anterior urethra, which includes that part of the canal 
in front of the triangular ligament, three orders of muciparous, 
glands open by means of ducts. These are the follicles of Littre, 
the lacunae or crypts of Morgagni, and Cowper's glands. All 
these glands are of the compound racemose type, consisting of 
acini which open into a common duct. (See Fig. 4.) The fol- 
licles of Littre are structurally the same as the crypts of Mor- 
gagni, but are smaller in dimensions. The lacuna magna in the 
fossa navicularis is a good illustration of a typical Morgagni' s. 
crypt. As shown in Fig. 5, it is a valve-like structure, at the 
bottom of which the duct of the gland opens. There may be 
several of these crypts along the roof of the urethra, but they are 
usually not found deeper than three inches. In Fig. 5 two of 
these valve-like pockets may be seen. 



36 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

Littre's follicles are quite numerous, and are seated mostly on 
the floor of the urethra and sometimes, though in less numbers, 
on its roof. The ducts of these follicles open obliquely forward 
toward the meatus, and by the naked eye or by the aid of a mag- 
nifying glass may be seen as very minute depressions in the mucous 
membrane. In Fig. 6 these follicles are indicated by the many 
minute bristles which have been passed into their ducts. 



Fig. 4. 




One of the mucous glands or follicles of Littre opening into the lumen ot the 
urethra : x y, lateral branches of main duct with their more superficially situated 
acini ; z z, continuation of main duct with deeply seated acini ; s s, trabecule of 
the cavernous tissue; ww, tunica albuginea. (Drawn from nature, much magni- 
fied.) 

Cowper's glands are two compound racemose bodies, seated just 
behind the anterior layer of the triangular ligament in the sub- 
stance of the compressor urethrse muscle. (See Fig. 11.) Their 
ducts are about three-quarters of an inch in T length, and they pass 
obliquely forward through the anterior layer of the triangular 



Fig. 5. 



ANATOMY. 37 

Fig. 6. 




Showing the lacuna magna and a deeper 
valve-like pocket and the orifices of numer- 
ous mucous glands. (Drawn from nature. ) 




I 






ligament and open separately into 
the bnlbons urethra on each side 
of the median line. (See Fig. 8.) 

All these glands and follicles 
secrete a clear, viscid mucus of 
alkaline reaction which resembles 
glycerin in appearance. It is prob- 
able the secretion of Littre's folli- 
cles and Morgagni's crypts is most 
developed for the lubrication of the 
urethral mucous membrane, but this 
fluid is also quite abundantly pro- 
duced during the sexual act. By 
some it is thought that the acidity 
of the urine left in the canal after 
micturition is neutralized by these 
secretions. The secretion of Cow- 
per^s glands is quite copious and 
similar in character to that just 




Showing roof of the urethra, 
with bristles passed into Littre's 
follicles. ( Drawn from nature. ) 



38 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

described. It forms part of the seminal discharge in coitus, 
and is frequently found in cases of sexual excitement without 
orgasm. This secretion plays an important part in certain sexual 
disturbances to be considered later. 



THE PROSTATE GLAND AND THE PROSTATIC 
URETHRA. 

The prostate gland is an accessory sexual organ of much im- 
portance, which also is employed in urination. In order to obtain 
a clear idea of this sexual gland it is necessary to study its struc- 
ture microscopically in young subjects, both children and animals, 
and then to trace its development at later periods of life. Such 
studies develop the following facts : 

The prostate is essentially a glandular organ, and the chief func- 
tion of its other component tissues, namely, the fibrous connective 
tissue framework and the unstriped muscular fibres, are : 1, to form 
a nidus for the lodgement of the glands, and, 2, to assist in their 
normal action. The glands are of the compound tubular type, and 
end in short ducts which open into the prostatic urethra. The 
ducts are merely fibrous tubes lined with columnar epithelium. 
The secreting portions of the glands are the tubules and the gland 
alveoli, which consist of longer or shorter, wavy, convoluted, 
branched tubes which terminate in saccular blind extremities. 
To some glands there are short lateral club-shaped branchlets. 
The secreting portions of these glands are lined by long, slender 
cells which are surrounded by a delicate connective tissue base- 
ment membrane in which bloodvessels, lymphatics, and nerves 
are seated. Outside the gland proper there are bundles of un- 
striped muscular fibres, some of which are circularly arranged, 
while others cross each other in various directions. By the con- 
traction of these muscular rings the secretion of these glands is 
thrown into the urethra. 

In the young normal prostate the glands are grouped in toler- 
ably well-defined lobules. This is well shown in Fig. 7, in which 
can be well made out eleven distinct lobular groups of prostatic 



ANATOMY. 39 

glands. In these lobules the tubular glands are inexplicably 
mixed up with each other very much as a bunch of earth-worms 
are, but all their ducts point toward the urethra. In the figure 
the irregular spaces in white are the glands cut through, but there 
are very many long tubules shown, which in the section happen to 
have been cut in the continuity of the glands. 

There is no muscular investment of the ducts of the glands, 
and it is probably owing to this condition that these outlets some- 

Fig. 7. 



Jk 






-0 ■ <*? ' 



.■■4?%^*£' : ^' — » 













■<~- * c ~ / "'— ^r : ' 



Showing section (much magnified) of normal prostate of a subject aged nine- 
teen years, made through middle of verumontanum : 1, urethra ; 2, verumonta- 
num ; 3, sinus pocularis; 4, ejaculatory ducts; 5, prostatic glands. (Drawn from 
the Edinger projection apparatus. ) 

times become plugged up with amyloid bodies, concretions, and 
calculi, which in all probability would be expelled by circular 
muscular fibres if they were present. 

There is no reservoir in the prostate gland for storing up or 
retaining its secretion. The latter in the sexual act is very copi- 
ously elaborated, and is quickly thrown into the prostatic urethra 
by means of the muscular mechanism which is so admirably 
adapted to that purpose. 



40 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

The prostatic urethra is normally about an inch and a quarter 
or an inch and a half in length, and extends from the apex to the 
base of the prostate. It has a calibre of 30 F. at the apex, 45 
in its middle portion, and 33 at its vesical end. It tunnels the 
prostate gland one-third nearer its upper than its lower surface, 
and its direction is downward and forward until it reaches the 
membranous urethra. 1 

When laid open on its upper surface the prostatic urethra is 
found to be of fusiform shape and to present certain anatomical 
peculiarities. (See Fig. 8.) On its floor is a narrow, longitu- 
dinal, wedge-shaped ridge called the verumontanum, the caput 
gallinaginis or crista galli. This structure, which is from one- 
half to three-quarters of an inch in length, and one or two lines 
in height, is composed of erectile tissue and muscular fibres and 
many tubular glands, all of which are covered with a dense mucous 
membrane. At each side and at the base of the verumontanum 
is a depression which is called the prostatic sinus, and it is upon 
the surface of these sinuses, right and left, that in a tolerably 
regular linear arrangement many prostatic ducts open, usually 
about twelve, and in some instances as many as twenty or 
thirty. 

The Sinus Pocularis. On the summit of the verumontanum, 
sometimes at its forepart and sometimes about its middle, a slit- 
like depression may be seen, which leads to a cul-de-sac or flask- 
shaped pouch about one-quarter to three-quarters of an inch in 
length and of a calibre of about three millimetres, which is 
directed upward and backward in the axis of the prostatic gland. 
This cul-de-sac, which is called the uterus masculinus, or sinus 
pocularis, is really a separate structure and distinct from, but sur- 
rounded by, the prostate. It consists of a secreting surface of 
columnar epithelial cells surrounded by connective tissue and 

1 The usual anatomical descriptions of the prostatic urethra are based on the 
position of the canal as found in the cadaver when it is laid flat on its back. In 
strict accuracy, the prostatic urethra in the living male, as he stands up, has an 
anterior and a posterior wall which are nearly in accord with the vertical axis of 
the body. 



ANATOMY. 



41 



bloodvessels and circular layers of unstriped muscular fibres. It 
may or may not Have blind diverticula. 

The function of the sinus pocularis is not known. It is thought 

Fig. 8. 




Showing bladder and urethra opened on the upper surface : 1, the trigone and 
openings of ureters ; 2, prostate and prostatic urethra ; 3, bulb of the urethra, 
■with openings of Cowper's glands ; 4, verumontanum, with orifice of sinus pocu- 
laris ; 5, openings of ejaculatoiy ducts ; 6, linear series of openings of prostatic 
ducts ; 7, groups of openings of prostatic ducts behind veruniontanum. ( Drawn 
from nature. ) 

by some that by reason of its position between the ejaculatoiy 
ducts, its round shape, and its well-developed musculature, in 
coitus it so contracts that it draws upon the openings of the ejacu- 



42 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

latory ducts, and thus renders them so patulous that the semen 
readily passes through. 

Prostatic Tubules. Upward and beyond the verumontanum 
there is a small mass of gland tissue enveloped in a connective 
tissue stroma and covered with mucous membrane which is pierced 
by the orifices of many gland-ducts. This tissue-mass is seated 
between the two lateral lobes, and it ends at the orifice of the 
bladder. In some subjects the development of this glandular 
area is very sparse, in others more luxuriant, while in a more 
limited class of subjects it is very exuberant. This mass of gland- 
ular tissue plays an important part in many young and middle-aged 
subjects in being the seat of a low grade of chronic inflammatory 
process, and in later life it may undergo such marked hyperplasia 
that a third lobe of the prostate is formed, which, becoming in- 
vested by a capsule derived from and continuous with that of the 
rest of the gland, offers more or less impediment to the passage of 
the urine. 

It will thus be seen that some of the ducts of the prostate 
gland open on each side of the verumontanum in a linear manner, 
and that there is also a group of them clustered in the tissue be- 
yond this structure as far as the vesical orifice. (See Fig. 8.) 

In the mucous membrane lying laterally beyond the region just 
mentioned we frequently find scattered here and there orifices of 
gland-ducts, but never in large number. 

On each side of the orifice of the sinus pocularis, or uterus 
masculinus, in the vertical walls of the verumontanum, are the 
slit-like openings of the ejaculatory ducts. In some cases one or 
both of these ducts open into the cavity of the sinus pocularis. 

In the anterior wall of the prostatic urethra, near its middle 
portion, are numerous venous channels, almost amounting to a 
plexus, which are superficially seated in a dense submucous tissue 
and covered only with mucous membrane. It is the injury of 
this plexus by careless sounding which sometimes gives rise to 
severe hemorrhage. 

There are three layers of unstriped muscular fibres in the pros- 
tatic urethra : (1) An internal circular layer immediately beneath 



ANATOMY. 43 

the raucous membrane ; (2) a middle longitudinal layer, which 
forms an imperfect sheet of muscle ; and (3) an outer, annular 
coat, which is continuous with the circular muscular fibres of the 
bladder. There are, in addition to the foregoing, the external 
and internal sphincters of unstriped muscular fibres of Henle, 
and in the capsule of the gland beneath the striped muscle is an 
independent thin layer of non-striped muscle, from which fasciculi 
pass inward and invest the ultimate groups of tubules. (See 
Fig. 7.) 

The arterial supply of the prostate is very considerable, and is 
derived from branches of the internal pudic, vesical, and hemor- 
rhoidal arteries. The veins are correspondingly large, and they 
end in a plexus which is situated at the side and base of the gland. 
There is also an abundant distribution of medullated and non- 
medullated nerves to these parts, which are derived from the 
pelvic plexus. 

In and about the verumontaniun there is an abundant supply 
of nerves of peculiar sensibility, and here it is thought that the 
seat of pleasure in the sexual act is centred. This part may be 
called the internal sensorium sexuale. 

The prostatic urethra in health ends abruptly at the vesical 
orifice, which is well shown in Fig. 8. When the gland under- 
goes enlargement, particularly when its third lobe is hyper- 
trophied, and also in the lateral lobe, it begins to pass beyond 
this vesical orifice, and may eventually extend into the bladder 
cavity. 

THE SEMINAL VESICLES. 

The seminal vesicles are two elongated and lobulated mem- 
branous pouches situated at the base of the bladder just beyond 
the prostate and in front of the rectum. The seminal vesicles 
have been erroneously and variously described as convoluted 
tubes, as little sacculated bladders, and as racemose glands. They 
are really blind-ending tubes with diverticula of various sizes. 

This can be seen from a study of Figs. 9 and 10. In Fig. 9 
the vesicle (1) is portrayed, divested of its loose connective 



44 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

tissue, and its three tubes are quite distinct to view. The ampl- 
iation of the vas deferens is also shown. In Fig. 10 the tubes 




Fio. 10. 




Showing the relation of the various parts of the seminal vesicles to each other 
and the ampullations : 1, seminal vesicle; 2, inner tube; 3, second tube; 4, 
outer or third tube, or handle of the jack-knife. (Drawn from nature. ) 

are shown dissected apart. The inner or first tube (2) is seen 
to have a decided distal enlargement. The middle or second 



ANATOMY. 



45 



tube (3) is seen to join the outer or third tube (4) at right angles. 
These two tubes (the third and fourth) bear the same relation to 
each other that the blade of a jack-knife bears to its handle. The 
outer enlarged tube, of dog's-ear shape, is called the handle of the 



Fig. 11. 




Under view of bladder and sexual apparatus and of urethra and prostate: 1, 
ureter ; 2, ampullation of vas deferens ; 3, seminal vesicle ; 4, prostate ; 5, 
Cowper's glands ; 6, bulb of urethra ; 7, membranous urethra ; 8, crus penis. 
( Drawn from nature. ) 

jack-knife, and the middle tube is its blade. When placed in 
natural coaptation the knife-blade fits snugly in the concavity ex- 
isting in the handle, and these lie side by side, all welded together 
by dense connective tissue with the first or inner tube. 



46 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

Each seminal vesicle measures two and a half inches in length, 
about half an inch (sometimes an inch) in breadth, and a quarter 
to a third or half an inch in thickness. (See Fig. 11.) 

The anterior or pointed extremities of the seminal vesicles are 
situated, when the bladder is empty, within a finger's breadth of 
each other on each side of the median line just above the base of 
the prostate. In this interval the ampullated end of each vas 
deferens joins the anterior pointed extremity or outlet duct of the 
seminal vesicle at a very acute angle, and, merging together, they 
form the ejaculatory duct. Thus there are two of these ducts — 
one on the right of the median line and one on the left — lying 

Fig. 12. 




Transverse section of the base of the bladder just behind the prostate, showing 
the relation of the seminal vesicles and the ampullations, which are embedded in 
a dense connective tissue stroma : 1 and 2, chambers of seminal vesicles ; 3, am- 
pullations of the vasa deferentia. 



very near to one another. These ejaculatory ducts enter the pros- 
tate at its base, tunnel its structure side by side (see Figs. 14 and 
15), pass downward and upward, and enter the prostatic urethra 
either on the sides of the sinus pocularis or into its cavity. 

Although the seminal vesicles and the ampullated extremities 
of the vasa deferentia lie very close to one another when the 
bladder is empty, when that viscus is normally distended these 
structures are separated from each other so that they form the 
letter V on the outside of the vesical wall. (See Fig. 11.) On 
the inside of the bladder at its base a Y-shaped space, corre- 
sponding to the external one just described, exists, which is called 
the trigone. (See Fig. 8.) It will be seen that in this figure, 



ANATOMY. 



47 



which is accurately drawn, the orifices of the ureters are unsyin- 
nietrically placed. 

The seminal vesicles have the usual muscular, connective tissue, 
and mucous membrane coats. Each portion of the vesicles has a 
calibre varying from 10 to 18 of the French scale (and in some 
young and vigorous subjects 30 French), while its outlet duct has 
a calibre of about 4 to 6 French, and sometimes less. (See Fig. 
12.) 

The epithelium lining the vesicles is of the columnar and 
cuboidal varieties. The mucous membrane, which is studded 
with the orifices of numerous tubular glands, is thrown into folds 
by which its extent is greatly increased. Thus the muscular 



Fig. 13. 




Showing the internal structure of the seminal vesicle and of the ampullation of 
the vas deferens, and the union of the two ducts which form the ejaculatory ducts : 
1, interior of the seminal vesicle ; 2, interior of ampulla ; 3, junction of the ducts 
forming the ejaculatory duct. (The section is taken in transverse diameter of the 
prostate and in the long axis of the seminal vesicles and vas deferens. Drawn 
from the Edinger projection apparatus. ) 

layers form trabecular, which produce many depressions and 
diverticula. (See Fig. 13.) In structure the seminal vesicles 
have thicker and denser walls than the ampullated parts of the 
vasa deferentia. They also have an abundant musculature, by 
the contraction of which the secretion is promptly expelled. 



48 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

The seminal vesicles are firmly welded to the prostate by means 
of dense, fibrous connective tissue, which, besides completely in- 
vesting the sacs, so adjusts the anatomical relation of the parts 
that the normal position of the ejaculatory ducts is always pre- 
served, and there is never danger of their being accidentally bent, 
twisted, or compressed. This condition of affairs is most impor- 
tant in coitus, since by it any hinderance to ejaculation is prevented. 

This perivascular connective tissue is also interesting in clinical 
practice, since in some cases inflammatory action extends beyond 
the vesicles themselves and involves it more or less extensively. 

The arterial and venous distribution of the seminal vesicles is 
very rich, and is derived from the middle and the inferior vesical 
and middle hemorrhoidal trunks. 

The nerve-supply is abundant, and is furnished by the pelvic 
plexus. 

The chief function of the seminal vesicles, besides acting as a 
storehouse for the spermatozoa, is the elaboration of a peculiar 
mucus in large quantity, which, in coitus, by its volume and force, 
carries along with it without impediment the seminal fluid, which 
exists in much more sparing quantity- in the ampullations of the 
vasa deferentia. 

In this connection it is well to call to mind the position and 
function of the seminal vesicles and of the ampullae, their imme- 
diate surroundings, and the conditions to which they are subjected 
in health, since such an understanding renders clear many patho- 
logical conditions which are now obscure. 

In health these seminal reservoirs, when the man is in the erect 
position, are seated nearly in a vertical position — that is, they are 
bags with their bodies high up and with their outlet ducts low 
down, looking downward and slightly forward. From their posi- 
tion one might think that their mucous contents might readily 
escape in obedience to the laws of gravitation. But we find that 
the secretion is retained in health in its reservoirs by wonderful 
provisions of nature. The healthy seminal secretion of these 
parts is very viscid, consequently it is not prone to leak out of 
the outlet ducts. In ill-health it is more fluid, and then it tends 



ANATOMY. 49 

to escape. Then we must consider the interior structure of these 
receptacles. They are not simply cavities like an egg-shell, but 
are composed of intricately arranged chambers with decidedly 
deep trabecule and diverticula, all of which tend to keep the 
secretion pent up until discharged by the functional activity of 
the parts. Then at the orifices of the outlet duct such is the 
compactness of the structure of the circular muscular fibres that 
they possess a certain tonus which prevents the escape of the 
contained secretion. It is probable, also, that in a measure the 
normal action of the musculature of the ejaculatory ducts so 
compresses these tubes that escape of secretion through them is 
prevented. The reduplicatures of the mucous membrane also 
helps to stop up these tubes. Therefore, we see that the condi- 
tions inherent in the secretions themselves and of the parts which 
hold them ready for discharge all tend to keep them well stored 
up until they are thrown out in ejaculation. In disease all this is 
changed, and tonus is replaced by lack of normal contractile power, 
and a general nabbiness and inertness of the parts are present. 
Then, with secretions less viscid than normal, and with loss of 
tonus and functional activity in the reservoirs and their outlet 
ducts, it is readily seen why these secretions escape. 

We must further fully consider the various influences to which 
the seminal vesicles and ampulla? are constantly subjected. Welded 
as they are to the base of the bladder, they undergo more or less 
expansion and contraction, according as that viscus is full or 
empty. In the act of urination, when the size of the bladder 
diminishes until it becomes a mere ball, there must be some 
pressure exerted upon these seminal appendages ; but in health, 
as a general rule, no expression of their contents is produced. 
Then, again, we must remember that the bladder and all struc- 
tures connected with it are necessarily more or less acted upon 
by intra-abdominal pressure (the weight of the intestines and 
their distention after eating, the distention of the rectum by gas 
or by feces, and abdominal fat), which in health does not, with 
very few exceptions, produce any change either in the vesicles or 
the ampulla?. Further than this, in the expulsive and contractile 

4 



50 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

efforts of the rectum, which lies immediately behind them, in defe- 
cation, particularly if the fecal mass is large and firm, consider- 
able pressure must be exerted upon these intimately connected 
parts, particularly when there is strong contraction of the levator 
ani muscle. Even with all these surrounding and neighboring 
forces acting upon the vesicles and ampulla?, they, as a rule, 
remain unaffected, and their secretion is not in any way abnor- 
mally disturbed. When these facts are fully understood much 
advance is made toward a clear and scientific comprehension of 
the nature and extent of seminal losses. 

The Ampullations of the Vasa Deferentia and the Ejaculatory 

Ducts. 

The ampul lated ends of the vasa deferentia are really expan- 
sions developed in these true spermatic canals at their point of 
juncture with the inner or first tube of the seminal vesicles at the 
niche in the base of the prostate. They have the same histo- 
logical structure and the same glandular supply as the seminal 
vesicles, except that their fibrous and muscular tissues are rather 
less copious ; but they are, nevertheless, firm and strong. The 
calibre of the ampullations of the vasa deferentia varies between 
6 and 10 French, but in vigorous young men it may be much 
larger. The internal structure of these dilated extremities of the 
spermatic canals is trabeculated like that of the vesicles, by which 
arrangement a greater amount of secreting surface is produced. 
(See Fig. 13.) There are present numerous tubular muciparous 
glands throughout their extent. These ampullae become narrowed 
just at the base of the prostate, and they then form a tube into 
which a bristle or a knitting-needle will pass without the use of 
much force. Around the orifices of these ducts the muscular 
tissue is somewhat increased in quantity, so that a not very well 
developed sphincter is formed. This duct is then joined by a 
duct of similar calibre, which is the prostatic end of the inner or 
first seminal vesicle tube. (See Fig. 13.) In this manner are 
formed the ejaculatory ducts, which are about three-quarters of 



ANATOMY. 



51 



an inch in length and have a calibre of about two millimetres. 
They run, as has already been stated, through the prostate down- 
ward and upward and open on each side of the verumontanum. 
(See Figs. 14 and 15.) The mucous membrane of the ejaculatory 
ducts contains tubular glands, is somewhat trabeculated, and from 
it numerous diverticula and duplicatures are developed. 

Fig. 14. 




Showing the position of the ejaculatory ducts in the upper part of the prostate 
and behind the urethra : 1, vesical orifice of the urethra ; 2, ejaculatory ducts. 
( Drawn from nature. ) 

Microscopical study of the structure of the ejaculatory ducts 
shows that their fibrous coat is not very thick, heavy, or con- 
densed, and that their muscular coat is correspondingly sparse 
and weak. A careful examination of these structures will con- 



Fig. 15. 




Showing the position of the ejaculatory ducts in the middle of the prostate 
under the verumontanum just before they turn upward and end in the prostatic 
urethra. ( Drawn from nature. ) 

vince the observer, I think, that their role in ejaculation is either 
passive or their function is to contract moderately after the ejacu- 
late has passed through them. There are no such firmness and 
density of structure of the ejaculatory ducts as there are in 
the vesicles and ampullae, whose expulsive power is very great, 



52 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

owing to the preponderating amount of unstriped muscular tissue. 
In the rhythmical process of ejaculation the secretion passes from 
above through the ejaculatory ducts, which then remain patulous, 
and it enters the prostatic urethra, and just as this occurs the 
prostate contracts quickly, firmly, and synchronously. The ejacu- 
latory ducts then contract as strongly as their feeble structure will 
allow them. Thus the ejaculate is thrown forward. 

The chief function of the ejaculatory ducts, however, seems to 
be secondary to that of the orifices of the seminal vesicle and 
ampullae. The sphincteric action of these orifices is quite power- 
ful, owing to the goodly quantity of circular muscular fibres. 
Now, added to this we have the secondary sphincteric action of 
the ejaculatory ducts, which closely compresses the lumen of these 
canals. It must be remembered that there is no fibrous and firm 
tube to occlude, but there are so many trabeculations and redu- 
plications in the mucous membrane of these ducts that by their 
coaptation alone the lumen is occluded, and by this condition, 
aided by moderate muscular contraction, they may be said to 
become normally plugged up, and thus offer a bar to the escape 
of secretions from above. In disease these parts become flabby 
and their muscular tonus is more or less lost. 

The Intrinsic and Extrinsic Muscles of the Sexual Apparatus. 

In the performance of the sexual function a number of corre- 
lated groups of muscles and muscular structures are concerned in 
the process of ejaculation, which are called intrinsic and extrinsic 
muscles. 

The intrinsic muscles, which are of the unstriped, involuntary 
variety, consist, first, of the musculature of the prostate and pros- 
tatic urethra, which are described on page 42 ; second, of the 
muscular fibres seated in the walls of the seminal vesicles, of the 
ampullations, and of the ejaculatory ducts, and those of the cir- 
cular and longitudinal muscular fibres connected with the corpus 
spongiosum. 

The extrinsic muscles are of the striped or voluntary variety, 



PLATE IV. 




ntrinsic and Extrinsic Muscles of the Sexual Apparatus. 



1. Corpus Spongiosum. 2. Bulbo-eavernous Muscle. 3. Isehio-eavernoii! 

Muscle. 4. Transversus Perinei Muscle. 5. External Sphincter Ani 

Muscle. 6. Levator Ani Muscle. 



ANATOMY. 53 

and they consist of some of the muscles of the male perineum, 
and of the anal region, and of some which belong to the penis 
proper. These are all well shown in Plate IV. 

It is unnecessary to fully and technically describe these various 
muscles, since all the facts can be readily ascertained by consult- 
ing any text-book on anatomy. These muscles are as follows : 
the bulbo-cavernous or accelerator urninse muscle, which surrounds 
the bulb and extends over the corpus spongiosum and on to the 
side of the corpora cavernosa for a length of fully two inches and 
perhaps more. These muscles compress the corpus spongiosum 
and bulb. Secondly, the ischio cavernous muscles, also called 
erector es penis, which are attached to the ramus of the ischium, 
and are inserted on each side into the crus penis, and by their 
action compress the parts and maintain erection. Thirdly, the 
transversus perinei, the external sphincter ani, and the levator 
ani, which give strength and firmness of support, and by their 
combined powerful contractions aid ejaculation of the semen. 
(See sections on the Mechanism of Ejaculation in the next 
chapter.) 

THE TESTES AND THE VASA DEFERENTIA. 

It is unnecessary in this work to give an elaborate and tech- 
nical description of the minute structure of the testes, but certain 
general facts concerning these glands should be emphasized. In 
the glandular portion of these organs we find the conical-shaped 
lobules whose apices end in the mediastinum testis. These lobules 
are formed of convoluted seminiferous tubules, in which are devel- 
oped the seminal cells and the spermatoblasts. (See Fig. 16.) 
Each lobule is enclosed in fibrous tissue, which forms the frame- 
work of the gland, its outer coat being the dense tunica albuginea, 
and its inner portion, less dense, being the mediastinum testis, 
through which the seminiferous tubes pass, turn upward at right 
angles, and perforate the upper inner portion of the tunica albu- 
ginea. Here they become much enlarged and convoluted, and 
form the globus major or head of the epididymis. All these 



54 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

minute seminal tubules then merge into one tube, which becomes 
much convoluted on itself and forms the body of the epididymis, 
which is the narrowed portion just below the globus major. Thi 
convoluted tube then forms a large mass, which is called the globus 
minor or tail of the epididymis. From the globus minor the tube 
ascends, growing less and less convoluted, and then forms the 
nearly straight tube — the vas deferens — which, with the vessels, 
lymphatics, and nerves, and its connective tissue sheath, consti- 



Fig. 16. 

Tunica Vaginalis. 
i\mica Albuginea. 
Its Septa. 




Showing intimate structure of the testis. ( From Gray's Anatomy. ) 

tutes the spermatic cord, which begins at the tail of the epididymis 
and ends at the internal abdominal ring. (See Plate V.) 

It is well to remember that in health the spermatic veins coming 
from the back of the testes become convoluted and form the pam- 
piniform plexus. In disease this tortuosity of the veins is more or 
less increased, and we have the condition known as varicocele. 

At the internal abdominal ring the vas deferens turns and 
descends into the pelvis, crosses the external iliac artery, curves 
around the bladder on the outer side of the epigastric artery and 



PLATE V. 



VAS DEFERENS 



JUNCTION OF 

PARIETAL 
AND VISCERAL 

LAYERS OF 
TUNICA VAGI- 
NALIS 




LOBUS MAJOR 



UPPER END 
OF TESTIS 
HYDATID 



LOWER END 
OF TESTIS 



PARIETAL LAYER OF 
TUNICA VAGINALIS 



Right Testicle, its External Surface. (Testut.) 



ANATOMY. 55 

inner side of the ureter, backward and downward to its base, 
where it becomes ampullated, as we have already seen. 

A survey of the structure of the testes shows that pathological 
changes which destroy the tubules and the lobules may give rise 
to sterility. In such an event, however, it would be necessary 
that all the glandular tissues of the organ should be destroyed. 
But it will be seen that the more vulnerable points are the medi- 
astinum testis, and the head, body, and tail of the epididymis. 
In these parts such infiltration and compression may take place 
that the efferent ducts are obliterated, and thus no spermatic cells 
or spermatozoa can escape from the testes. 



CHAPTER III. 

THE PHYSIOLOGY OF THE MALE SEXUAL FUNCTION. 

Having acquired a clear knowledge of the anatomy and struc- 
ture of the sexual apparatus, it is now necessary to study in detail 
the physiology of the sexual function. To this end it is necessary 
to describe in a lucid and concise manner the mechanism of erec- 
tion, the mechanism of ejaculation, and the nature and composition 
of the seminal fluid. 

THE MECHANISM OF ERECTION. 

In order to understand the mechanism of erection, or that state 
of rigidity of the penis necessary for intromission and copulation, 
the facts connected with the anatomy and physiology of the gen- 
ital apparatus already brought out should be recalled to mind. 
Concisely stated, this condition of erection may be induced by 
psychical or tactile influences, or by the combination of both. 

Sexual impulses, as we have seen, originate in a sexual centre 
which is seated in the lower lumbar part of the spinal cord. This 
centre is stimulated into functional activity by impressions or sen- 
sations which originate in the brain, and are transmitted through 
the pedunculi cerebri and the pons down the spinal cord to it, and 
also by excitation and frictional influences which are applied to 
some part of the penis — i. e., glans, frsenum, fossa navicularis, 
or integument. In the first place, the mental excitation throws 
the genital centre into a condition of erethism, which immediately 
acts upon the penis and its accessory sexual organs by means of 
the nervi erigentes, and causes its rigid condition. In the second 
case the peripheral nerve irritation is transmitted backward to 
the sexual centre by means of the sensory nerves, which throws 



PHYSIOLOGY OF THE 31 ALE SEXUAL FUNCTION. 57 

the centre into a condition of excitation, which is reflected or 
carried outward to the penis by the nervi erigentes, and erection 
follows. 

It is thought by some authors that besides the sexual centre 
which governs erection there is also a centre for ejaculation. 
This view is mainly based on the not very uncommon occurrence 
of erection without ejaculation. In many cases in which coitus 
is thus interrupted some inhibitive influence is undoubtedly trans- 
mitted from the brain, and in these cases at least there seems to 
be no necessity for supposing that there is an ejaculatory centre 
the function of which is disturbed. 

Thus we see that the requirements for erection are : first, a 
healthy and stable condition of the genital centre ; secondly, a 
perfect competence on the part of the nerves which originate 
in the brain and of the erigentes and sensory nerves to transmit 
the influences of excitation which are communicated to them. 

Stimulation of the sexual centres with resulting erection may 
also occur through influences brought to bear upon the prostatic 
urethra. Thus friction of this point by instruments and appli- 
ances passed down the urethral canal, either by the surgeon or by 
the individual himself for erotic purposes, excites the genital centre, 
which reacts through the nervi erigentes upon the penis. Calculi 
in the prostatic urethra and distention of the canal by urine also 
produce a similar effect. 

Then, again, injury or disease of the lower part of the spinal 
cord may cause erections by means of the irritation transmitted 
from the sexual centre to the penis. 

The physiological actions involved in erection of the penis are 
very instructive and interesting. Under the influence of stimu- 
lation of the nervi erigentes, derived, as we have seen, from the 
sexual centre in the lumbar part of the spinal cord, a vasodilator 
action takes place in all the erectile tissues of the penis. Coin- 
cidently with the nervous excitation and vasodilator action, relax- 
ation of the muscular bundles and fibres of the trabecule of the 
cavernous and spongy bodies occurs, and thus the full distention 
of the blood sinuses and cavities is rendered possible. In propor- 



58 SEXUAL DISORDERS OF THE MALE AND FEMALE 

(ion, therefore, as the afflux of blood from the arterial capillaries is 
abundant and the muscular relaxation is complete, so is the erec- 
tion moderate or very firm. 

Although little is said on the subject by authors, it is possible 
that the sympathetic nerves of the erectile tissues play an impor- 
tant part in the production of erections. The function of these 
sympathetic nerves is in immediate reciprocal relation with that 
of the cerebro-spinal nerves. The former induce relaxation of 
tissues and vascular dilatation, while the latter, the excitor 
nerves, are concerned in the prompt and full supply of blood to 
the trabecular. If, however, the condition of the blood-supply 
were not safeguarded, and if an impediment were not provided 
against immediate escape and return of that fluid to the body by 
the veins, erections would in all cases be abortive or of very short 
duration. But perfect stability is insured and maintained by cer- 
tain anatomical conditions. With the filling of the trabecular there 
naturally occurs an engorgement of the venous sinuses, which, in 
its turn, so compresses the large longitudinal veins of the penis 
that decided stasis occurs, and thus the volume of distention of 
the penis is materially increased and maintained until orgasm or 
ejaculation has occurred. 

Further than this, the engorgement of the penis is also mate- 
rially enhanced by the direct action of various extrinsic muscles, 
namely, the bulbo-cavernous muscle, which compresses the erectile 
tissue of the bulb as well as the dorsal vein of the penis, and of 
the erector penis and the transversus perinei, which compress the 
crus penis and retard the return -supply of blood. The levator 
ani also acts as a powerful extrinsic compressor of the parts. (See 
page 52, and Plate IV.) 

The mechanism of erection, therefore, depends on a peculiar 
nervous stimulation which results in a well-defined temporary 
blood-engorgement of the penis. 



PHYSIOLOGY OF THE MALE SEXUAL FUNCTION. 59 

THE MECHANISM OF EJACULATION. 

The combined physiological processes which take place in the 
production of erection are preparatory to the completion of the 
sexual act, which culminates, in coitus, with emission or ejacula- 
tion. The emission of semen is produced by a series of complex but 
correlated agencies involving the whole sexual sphere. Whether 
there is a special sexual centre for ejaculation, as has been stated 
before, is doubtful. With the development of the erotic impres- 
sion and the erection of the penis the testicles are, in all prob- 
ability, thrown into a condition of increased functional activity. 
The first visible evidence of the participation of these glands in 
copulation or sexual erethism is the strong action of the cremaster 
muscles, which draw them quite tightly up to the internal abdom- 
inal rings. Synchronously semen escapes from the coni vasculosi 
of the epididymes and reaches the vasa deferentia. Arrived in 
these tubes, the strong circular muscular fibres contract power- 
fully and rhythmically, and the fluid is forced up to the ampul- 
lations of these tubes, which then become very much distended. 
At this moment the seminal vesicles become functionally active, 
and they contract and expel part of their contents synchronously 
with a similar action of the ampullations of the vasa deferentia. 
The seminal fluid in relatively small quantity is thus mingled 
with the copious ejaculate of the seminal vesicles, and the mix- 
ture thus produced is thrown through the ejaculatory ducts, the 
mucous membranes of which take on functional activity and add 
their quota of mucous fluid, by strong muscular action, into the 
prostatic urethra. While this part of the function has been going 
on the follicles of the prostate and the sinus pocularis have been 
active in the elaboration and expulsion of their secretions into the 
prostatic urethra. At this moment the caput gallinaginis becomes 
swollen and erect, and it so adjusts itself that in the normal state 
the seminal fluid must go forward through the now patulous ori- 
fices of the ejaculatory ducts, and cannot pass backward. At this 
time the compressor urethral muscle is so relaxed that it offers no 
impediment to the escape of the semen, which is thrown out of 



60 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

the prostatic urethra by means of the complex but powerful mus- 
culature of this gland. At this crisis it is believed that the pecu- 
liar sensation of the sexual orgasm is experienced. The combined 
secretion of the ampullations, of the vasa deferentia, of the semi- 
nal veiscles, of the prostate, of the sinus pocularis, and of the 
ejaculatory ducts then flows into and distends the bulbous urethra, 
being there mixed with the secretion of Cowper's glands. Then 
the circular muscular fibres of this portion of the urethra contract 
forcibly, and at the same time the accelerator urinse muscles con- 
tract upon the bulbous urethra, and thus the ejaculate is quite 
forcibly thrown along the urethra and out of the meatus. In its 
passage through the penile urethra the ejaculation. of the seminal 
fluid is further accelerated by the rhythmical contraction of the 
circular muscular fibres of the corpus spongiosum. The secretion 
of Littre's follicles and Morgagni's crypts lubricates the urethral 
canal and adds somewhat to the volume of the ejaculate. In the 
act of ejaculation it can be seen that unstriped muscular fibres, 
the intrinsic muscular tissue of the sexual apparatus, play a very 
important part ; but the completion of the act is largely aided by 
the powerful contraction of the extrinsic muscles, the levator ani, 
the external sphincter of Henle, the ischio caver nosus muscle, and 
the transversus perinei. As stated by Foster, 1 "A contraction 
begins in the external sphincter ani, extends to the levator ani, 
and then passes to the other muscles, progressing in a wave-like 
manner from behind forward, and is repeated in a more or less 
distinctly rhythmic manner until all the semen is ejected from the 
urethra." 

1 A Text-book of Physiology. Part iv. p. 373. London, 1891. 



CHAPTER IV. 

NATUEE AND COMPOSITION OF THE SEMINAL FLUID. 

The proper performance of the sexual function in the human 
race, the natural outcome of which is the propagation of the spe- 
cies, requires not only the integrity of the composite mechanism 
of the sexual apparatus, but also the elaboration of healthy semi- 
nal fluid in normal quantity. A clear knowledge of the nature 
and composition of this secretion in health is absolutely necessary 
to the understanding of the changes which take place in it as a 
result of disease. 

THE SEMEN. 

The semen is a composite liquid of a whitish, opaline color, 
somewhat resembling starch paste, alkaline in reaction, and viscid 
and ropy in consistence. It emits a peculiar odor, like that of 
sawed bone. It is the combined secretion of the testicles, of the 
seminal vesicles, of the prostate gland, of Cowper's glands, and of 
the muciparous glands of the urethra. According to Miescher, 1 
whose conclusions have been accepted by the best authorities, the 
composition of semen is as follows : Water, 82 to 90 per cent., the 
remainder composed of serum albumin, alkali albuminate, henii- 
albuminose, nuclein, lecithin, guanin, hypoxanthin, protomin, fat, 
cholesterin, inorganic salts, and phosphoric acid, muriatic acid in 
combination with inorganic salts, and organic bases. 

When semen is examined under the microscope we find sperma- 
tozoa, seminal bodies, and very fine seminal granules, with per- 
haps a few epithelial cells and crystals of phosphates, chiefly of 
magnesia and lime. 

1 Verhandl. der Naturfor. Gesellsch. zu Basel, 1874, Band vi., Heft 21, p. 138. 



62 SEXUAL DISORDERS OF THE MALE AND FEMALE. 



Spermatogenesis. It is important here to call to mind the 
essential facts concerning spermatogenesis. Upon the endothe- 
lioid basement membrane of the convoluted seminiferous tubules 
the nucleated parietal cells are seated, the outermost layer of which 
is composed of sustentacular cells, which are not concerned in pro- 
ducing spermatic elements. Inside and on the foregoing layer are 
the spermatogenetic cells, of which the outer ones are the longer, 
or mother-cells, and the inner ones the smaller or daughter-cells. 
From the nuclei of the latter cells spermatoblasts are developed, 
and from these structures the spermatozoa are directly formed. 
(See Fig. 17.) 

Fig. 17. 




Showing transverse section of human seminiferous tubule : 1, membrana pro- 
pria ; 2, zone of parietal cells ; 3, mother-cells undergoing division ; 4, partially 
developed spermatozoa ; 5, enveloping connective tissue. (After Peaesol. ) 

The spermatoblasts are closely packed together, side by side, in a 
finely granular semigelatinous substance. They gradually become 
elongated and bean-shaped, and finally are elaborated into fully 
developed spermatozoa. Pearsol and others state that each 
spermatozoon is developed from the nucleus of a spermatoblast. 

The secreting portion of the testes is confined to the convoluted 
seminiferous tubules. From this part of the organ the sperma- 



NATURE AND COMPOSITION OF THE SEMINAL FLUID. 63 

tozoa enter the straight tubes or canals, pass into the vasa eff er- 
entia, and from there through all the manifold convolutions of the 
epididymis until they reach the vas deferens, which they traverse 
until they arrive at the deferential ampullations and seminal vesi- 
cles, where they remain until ejaculation occurs. The migration 
of spermatozoa, probably, is effected by their own vibratile move- 
ments, but there are certain delicate vital and mechanical aids 
which speed them on their journey. From the beginning of the 



Fig. 18. 




Showing section of a tubule of the human epididymis: 1, membrana propria; 
2, columnar cells crowned with, 3, long cilia; 4, layer of non-striped muscular 
fibres ; 5, intertubular connective tissue ; 6, masses of spermatozoa in the lumen 
of the tube. ( After Peaesol. ) 

straight tubules up to the ampullated expansions the seminal 
canals are lined with ciliated columnar epithelium and surrounded 
by circular layers of unstriped muscular fibres, so that, in addition 
to their own motility, these bodies receive propulsion from the 
motion of the cilia, and also by the rhythmical contraction of the 
muscular rings. (See Fig. 18.) It will thus be seen that the 
process of spermatogenesis is a most delicate and elaborate one, 



64 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

and that the mechanism of transportation of these vitalized bodies 
is wonderfully Intricate and effective. 

The spermatozoa are highly vitalized elements composed of a 
head and a cilinm or tail, and in their shape resemble tadpoles. 
The head viewed on its broad surface is oval in shape, but when 
examined on its side it appears somewhat triangular or wedge- 
shaped. The length of a spermatozoon is 50 to 60 ft, of which 
the head is 3 to 5 /i, while the rest consists of the thin, tapering 
tail. The seminal bodies or cells are of considerable size, have a 
well-defined outline and granular appearance, and contain nuclei. 
The smaller cells are about four times the size of pus -corpuscles, 
and contain a large nucleus and much granular protoplasm. The 
large cells are oval or irregular in shape, and they may contain 
several nuclei. Under high powers seminal cells show a fibrous 
structure. In my examinations I have most encountered the 
seminal cells in the semen of young men and in those of early 
middle age. It is not, I think, common to observe them in the 
semen of men past fifty years of age. In such subjects we usually 
find spermatozoa and seminal granules. 

The seminal granules are extremely minute and fine, sometimes 
presenting a yellowish color, again having a greasy appearance. 
They have a much less refractive capacity than amorphous phos- 
phates and carbonates, are very much smaller, and are scattered 
evenly over the microscopic picture. 

When healthy semen is allowed to stand in a test-tube the 
tissue-elements slowly settle to the bottom, and in about twelve 
hours we find that it presents two layers of equal bulk, an upper 
one, which is of the consistence of semen, and may be slightly 
turbid or perfectly clear, and a lower one, which is opaque, and 
looks like starch or tragacanth paste. The lower layer is com- 
posed almost wholly of spermatozoa. 

According to Mehu, 1 healthy semen should on evaporation 
yield 10 per cent, of its weight in organic and inorganic matters. 

1 Kemarques eur les Variations de la Composition du Sperme dans quelques cas 
pathologiques. Annales des Mai. des Org. Gen.-urin., Tomei. pp. 303 et seq. 



NATURE AND COMPOSITION OF THE SEMINAL FLUID. 65 

With the change in the composition of the fluid due to disease, 
local or general, this quantity is proportionately lowered. In 
azoospermatous semen the solid constituents are diminished about 
one-half in quantity. 

The microscopic picture of fresh, healthy semen presents a 
bewildering appearance. It looks, as Ultzmann says, " as if an 
ant-hill had been stirred up with a stick." The spermatozoa 
squirm about in the most lively manner, and there being so many 
of them, and all of them going in zigzags, the eye may become 

Fig. 19. 




Showing spermatozoa and seminal cells. 



confused by the sight. Their propulsive power is sometimes well 
shown when they easily push crystals of inorganic salts several 
times their size, and scattered over the field, out of their way. 

As a rule, it may be stated that in spermatozoa which have died 
after ejaculation the tail is well outstretched or slightly bent at the 
end, whereas when they have been discharged dead the tail is 
usually curled up or much twisted. In Fig. 19 spermatozoa are 
shown as they appear under the microscope in life. The speci- 
men from which this figure was made was secured from a sper- 

5 



6Q SEXUAL DISORDERS OF THE MALE AND FEMALE. 

ma tic cyst in a vigorous young man. The heat applied to the 
object-glass in the drying process necessary to staining suddenly 
killed the zoosperms when they were wriggling in a very lively 
manner over the field. These spermatozoa, which are very large 
and have very long tails, are good examples of these bodies in 
strong, healthy men. 

In weak, anaemic persons and in old men spermatozoa may be 
smaller than normal, having strikingly small and thin heads and 
short tails, and showing much less vigor of motion. On the other 
hand, in some young and robust men they may be of exceptional 
size and very vigorous in their movements. In water, spermatozoa 
soon become motionless, but in alkaline or salt solutions, as well 
as in those containing sugar, albumin, and urea, they seem very 
vigorous. Cold, acids, and solutions of metallic salts quite quickly 
kill these bodies. In the vagina the conditions seem favorable 
for the life of spermatozoa, and it is stated that they have been 
found in the cervical canal seven days after coitus. 

Up to puberty the seminal fluid contains seminal granules but 
no spermatozoa, and from that period until the age of fifty years, 
and even beyond in well-preserved subjects, these bodies are healthy 
and abundant. Toward sixty decrease in size, number, and vital 
energy is usually noted in spermatozoa. 

Though authentic cases have been reported in which sperma- 
tozoa were found in the semen of men of seventy and eighty years, 
and even beyond these advanced ages, and although men over 
ninety years old have been known to procreate children, such 
occurrences cannot be taken to constitute a rule, and they must 
be looked upon as very exceptional. A fair average, I think, of 
the limit of many men's virility in general is between sixty and 
seventy or even seventy-five years, though there are very many 
men whose sexual powers and desires cease much earlier. It 
must be remembered that although spermatozoa may be found in 
the semen of aged men, it does not follow that they possess the 
vital energy necessary to the fructification of the female ovule. 

The number of spermatozoa, as well as their structure and 
virility, varies according to the constitution of the producer. In 



NATURE AND COMPOSITION OF THE SEMINAL FLUID. 67 

vigorous, robust meu they are found in abundance in a healthy 
condition. 

Lode/ by computation, estimates that at each normal ejacula- 
tion a man discharges two hundred and twenty-five million sper- 
matozoa. Guelliot, 2 however, thinks that this estimate is too 
small, and claims that in his researches the figures reached were 
four hundred and twelve million five hundred thousand sperma- 
tozoa. 

In less robust persons these bodies are less abundant and have 
less vital energy, while in weak and debilitated individuals they 
are usually small in quantity and feeble in vitality. In some 
persons they are after ejaculation rapidly replaced by a new crop, 
while in others their generation is slow and meagre. During 
acute illness of various kinds the function of the testicle is not 
performed, and in chronic diseases the development of spermatozoa 
is slow, intermittent, and slightly productive. 

Extended post-mortem studies made under my direction clearly 
show that the more nearly normal the sexual organs and function 
are at the time of death the greater is the number of spermatozoa 
in the seminal vesicles and the ampullae of the vas deferens. 

In one case of miliary tuberculosis, in a patient aged fifty-five 
years, the seminal vesicles were found contracted, their cavities 
closed and entirely devoid of spermatozoa. In a case of tuber- 
cular peritonitis and in one of chronic uraemia no spermatozoa 
were found in either ampulla or vesicle. All of these cases had 
been in very low general condition for from two to four weeks 
before death. 

In two cases of pneumonia there were distinctly more sperma- 
tozoa in the ampullae than in the seminal vesicles. 

In five cases the spermatozoa in the ampullae and vesicles were 
very numerous and nearly equal in number. These cases include : 
fracture of the skull, age twenty-two years ; cerebral hemorrhage, 

1 Ueber spermaproduction beim Menschen und Hunde. Wien. klin. Wochen- 
schrift, 1891, Band iv. p. 907. 

2 La Numeration des Spermatozoi'des. Annales des Mai. des Org. Gen.-urin., 
1892, Tome x. pp. 77 et seq. 



70 SEXUAL DISORDERS OF THE MALE AND FEMALE. 



Fig. 20.) The greater part of the field is covered with large, 
medium-sized, and small globular masses of mucus, which, when 
once recognized, will afterward be readily detected. These globu- 
lar masses are well shown in Fig. 20. It can be seen that they 
have no structure, and they may be mistaken for globules of oil 
or air-bubbles. They are less refractive of light than air or oil, 
and sometimes they have a whitish tint, like that of moon-stones. 
They may be of oval or of irregular shapes. They are surrounded 
by small quantities of granular phosphates, and spermatozoa may 



Fig. 20. 




J 



Normal secretion of the seminal vesicles. 

be seen intermingled with them. It is important to have a clear 
idea of the composition of this secretion in health, in order to 
compare it with the appearances found in disease. 

The secretion of the seminal vesicles is relatively quite copious, 
and by its viscidity, large quantity, and the force of its propul- 
sion in coitus it carries the spermatozoa along in the rushing 
current toward the prostatic urethra. Besides this function, this 
secretion serves as a very efficient diluting agent in the seminal 
ejaculate. 



NATURE AND COMPOSITION OF THE SEMINAL FLUID. 71 

Even in health, but usually as a result of a chronic inflamma- 
tory process, we may find calcareous concretions and certain little 
yellowish masses, presumably of organic or inorganic origin, com- 
posed probably of phosphates and mucus, which are called sym- 
pexia. Blood-corpuscles also may be noted as an accidental ad- 
mixture. In some instances, under the microscope, epithelial cells 
of the columnar variety may be found. No ciliated epithelial 
cells are found in any part of the seminal vesicles. 

The Secretion of the Prostate Gland. 

The secretion of the prostate gland in a state of health is a thin 
liquid of alkaline reaction and milky color, and from it the odor 
of the semen is derived. It serves to dilute and render less viscid 
the secretion of the ampullations and seminal vesicles, and to exert 
a nutritional influence on the spermatozoa. When taken by aspi- 
ration and with care that there be no foreign admixture, from a 
perfectly healthy prostate of a recently dead individual, the liquid 
has the appearance just described, and under the microscope it is 
found to contain cylindrical cells and some granular phosphates. 
The amount of mucus in the secretion is not great. In Fig. 21 
the microscopic picture of the prostatic fluid taken immediately 
after the sudden death of a young man whose gland was in a state 
of perfect health is well shown. Many examinations have con- 
vinced me that this is a typical microscopic picture of the normal 
prostatic secretion. In health the granular phosphates are seen 
to be not very copious in the secretion under the microscope, but 
in disease these granules become very copious. (See Fig. 21, also 
sections on Affections of the Prostate.) 

The prostate has no apparatus for storing its secretion, there- 
fore the latter is elaborated in periods of functional activity and 
of sexual excitement. There is usually a very moderate amount 
of secretion in the tubules in the quiescent state, and this can be 
obtained in small quantities after death, provided great care is 
taken in the removal of the sexual organs from the pelvic cavity. 

It is claimed by a number of writers that the prostatic secre- 



72 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

tion contains an organic base, which, when acted upon by a chem- 
ical solution, becomes converted into what are known as Bottcher's 
Bperma-crystals. 

Bottcher's Sperma- crystals. These crystals are interesting 
curiosities rather than valuable diagnostic indices. They are 
obtained by mixing about equal parts of azoospermatous semen 
and a 1 per cent, watery solution of phosphate of ammonium. 
In this combination these crystals quite quickly form in great 
numbers. When normal semen is mixed with the phosphate of 

Fig. 21. 




Showing normal prostatic secretion of a young man. 



ammonium solution these crystals form quite slowly and may be 
somewhat smaller in size. It is not uncommon to look in vain 
for them in this combination, since they are not invariably formed. 
Sperma-crystals are colorless, very transparent, and of quite 
large size. The dominating forms of these crystals (see Fig. 22) 
are in the shape of daggers or of cuttle-fish. In the first there is 
a median elevation, or ridge, which slopes gradually to the sides 
of the crystals ; in the second the surface is moderately convex. 
In many crystals the dagger's point is broken off, and in others 



NATURE AND COMPOSITION OF THE SEMINAL FLUID. 73 

it does not exist, as each end of the crystal is cut off at an oblique 
angle. These crystals are sometimes so long that their whole 
length cannot be viewed in one microscopic field. In some crys- 
tals a very fine longitudinal striation can, be made out. When 
fractured these long crystals sometimes have jagged ends, like a 
broken piece of wood. There is a marked tendency of the crys- 
tals to group together, to lie side by side and upon and across one 
another, and they sometimes appear to pierce and fuse with each 
other, and without break or fissure to form a cross. It is not 
uncommon to find a rosette-like arrangement of crystals which 



Fig. 22. 




Bottcher's sperma-ciystals. 

is very pretty. Then, again, we may find rhomboidal forms, and 
even thick, square crystals. Although sperma-crystals suggest to 
the eye the appearance of ammonio-magnesian phosphate, a little 
examination will soon show that they are rather less translucent 
and brilliant and more uniformly dagger-shaped. 

The interest in these crystals centres in the fact that they are 
supposed to be the result of a combination of an organic base 
with an ammonio-phosphate salt. The organic base is thought 
by Bottcher, Schreiner, and Poehl to be derived from the semi- 
nal fluid, and is called by the latter spermin. Furbringer claims 
that this organic base exists only in the prostatic fluid ; therefore, 



74 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

when these crystals are formed after the addition of the ammonio- 
phosphate solution to a secretion derived from the sexual tract 
that secretion must have come from the prostate. On the other 
hand, the more recent observations of Lubarsch 1 have convinced 
him that Furbringer is wrong, aud that these crystals have as 
their organic base the epithelial cells of the testicles. 

Seeing that we now have reliable descriptions and facts as to 
the microscopic appearance of the secretion of the seminal vesicles, 
of the ampullae, and of the prostate, it is no longer necessary to en- 
deavor to fortify the diagnosis by the development and discovery of 
Bottcher's crystals, the opportunity of which very often fails, while 
the experiment in many instances comes to naught. It may be of 
interest here to state the fact that the crystals depicted in Fig. 22 
were found in the azoospermatous semen of a man, aged thirty- 
four, treated in the usual way by me, which secretion, when unmixed 
Avith the chemical, contained very many seminal cells, all of which 
disappeared with the development of Bottcher's crystals. This, 
though a single, well-studied observation, is in striking support of 
Lubarsch' s contention. 

The secretion of the ejaculatory ducts and of the sinus pocu- 
laris is in all probability simple mucus, and is not very copiously 
produced. 

The Secretion of Littre's Follicles, of the Crypts of Morgagni, 
and of Cowper's Glands. 

In periods of sexual excitement Littre's follicles, Morgagni's 
crypts, and Cowper's glands give forth a quite abundant secretion 
of clear, viscid, thready, alkaline mucus, which looks like the 
white of an egg (unboiled) or glycerin. This secretion differs 
markedly from the secretion furnished by the deeper parts of the 
sexual apparatus. It is thrown into the urethra anterior to the 
triangular ligament, and is very frequently found without any 
admixture of secretion from the deeper parts. This secretion 
seems to be concerned in the dilution of the semen. Its chief 

1 Deut. med. Wochenschrift, 1896, No. 47. 



NATURE AND COMPOSITION OF THE SEMINAL FLUID. 75. 

function, however, is to neutralize the anterior urethra, which is 
usually rendered acid by the passage of urine. It also acts as 
an efficient lubricant in preparing the urethra for the transmission 
of the seminal discharges. A portion at least of the secretion of 
the glands under consideration appears during erection and before 
ejaculation in the shape of one or two clear drops, which are seen 
at the orifice of the meatus. 

Under the microscope we find in this secretion strings of mucin, 
flat or cylindrical epithelial cells, and perhaps a few coffin-shaped 
crystals of phosphate of magnesia or lime. This secretion, which 
is known when abundant under the name urethorrhoea ex libidine, 
is usually of no significance whatever. It is found, as a rule, in 
cases of sexual excitement, especially when it is great and pro- 
longed. It may also be observed in cases of excessive sexual 
indulgence and of masturbation in young men, and is seen in 
cases in which men, for various reasons, injuriously and frequently 
press the glans penis between the thumb and forefinger. 

This secretion first appears as a thin cloud in the urine, -and 
then slowly settles to the bottom of the glass, from which it may 
be secured for microscopic examination by means of the pipette 
as a small, clear, gelatinous mass. 

If the man has had a recent seminal emission or has indulged 
in coitus within a few hours, some spermatozoa may have been left 
in the urethra and have become entangled in this secretion. This 
accidental occurrence may perhaps not be recognized by the micro- 
scope, and erroneous ideas as to the nature of the secretion are 
liable then to be formed. This fact should be remembered in 
clinical practice. 



CHAPTER V. 

IMPOTENCE IN THE MALE. 

By the term impotence is understood a diminution or complete 
loss of power to perform normal coitus. In the sexual act the 
most essential factors are the natural desire and a state of erection 
of the penis, without which intromission is impossible. 

Normal sexual intercourse varies very greatly in different indi- 
viduals. In some men a condition of marked virility exists, while 
in others the sexual appetite and power are much less fully devel- 
oped. As a broad, general rule, men having strong, robust consti- 
tutions are sexually very potent, and in proportion as the general 
standard of health is lessened so are the sexual appetite and power 
diminished. Exceptions to this general average are sometimes 
seen in neurotic and lustful persons, who, though not physically 
strong, have a constant desire for sexual indulgence. In these 
cases, however, decline sets in sooner or later, and impotence in 
varying degrees may then be present. 

Sexual vigor, therefore, is a relative term, since what might be 
called full virility in one man would feebly compare with the 
marked sexual capacity in another. In order to understand the 
various features of sexual impotence in the male, it is necessary, 
as I have already said, for the reader to have a clear knowledge 
of the anatomy and physiology of the sexual organs, of the 
mechanism of the sexual act, and of the nature of the seminal 
fluid. (See Chapters II., III., and IV.) 

By the term impotence a number of closely connected condi- 
tions and functions are included which demand a systematic 
recital. In the first place, the controlling influence or sexual 
desire must be present, and this requirement can only be fulfilled 
when the brain is undisturbed and when the environment of the 
patient is calm and satisfactory. The second essential is the erec- 



IMPOTENCE IN THE MALE. 77 

tion, which depends upon the integrity of the brain and the sexual 
system and upon the harmonious working of the vascular and ner- 
vous systems. When these intricate and correlated conditions are 
in accord the consummation of the sexual act in orgasm and ejacula- 
tion takes place, and the man may be said to be sexually potent. 

Impairment of sexual desire may result from causes and condi- 
tions soon to be considered. Imperfect erections may be due to 
mental causes or to a number of physical conditions, which even 
with erection may interfere with the sexual act and render it pre- 
mature, weak, or even prevent its consummation. When impo- 
tence in the male is considered in detail it is found that : 1, there 
may be absence or impairment of desire ; 2, absence of the power 
of erection and intromission ; 3, absence or diminution of the 
power of ejaculating the seminal fluid ; and, 4, a lowered standard 
of or an entire absence of orgasm. 

In most cases of male impotence the fertility of the semen 
remains intact, and impregnation of the female is reasonably 
probable if the male organ is sufficiently potent to discharge it 
in the proper place. In the event of partial intromission, even 
when of short duration, impregnation of the female may occur ; 
but when intromission is impossible a man naturally becomes 
sterile, although his semen may be fertile. 

When the whole subject of male impotence is carefully gone 
over, it is found that the various cases may be conveniently sub- 
divided and arranged in four distinct groups. To the first, in 
which brain-impressions play a prominent part, we may apply the 
term Psychical Impotence. The second class of cases, in which 
some damage, limited to one or more portions of the sexual sphere, 
is the underlying cause, and the impotence a symptom thereof, the 
term Symptomatic Impotence is applicable. When impotence is 
due to impairment of the sexually controlling parts of the nervous 
system, owing to various depressing causes, it may very properly 
be designated Atonic Impotence. And, fourthly, when any struc- 
tural defect or disease so disturbs or cripples the penis that intro- 
mission is interfered with or rendered impossible, the condition 
may be termed Organic Impotence. 



CHAPTER VI. 

PSYCHICAL IMPOTENCE. 

The term psychical impotence is applied to certain conditions 
of sexual weakness or inability in which mental impressions inter- 
fere more or less with sexual desire and with erection and ejacula- 
tion. In many cases of this form of impotence the sexual organs 
are in a perfectly normal condition ; in others there may be some 
mild abnormality, but the dominating cause in all arises in the 
brain and in the impressions which it conveys. Whatever may 
be the condition operating on the mind, an inhibitory effect is pro- 
duced upon the sexual centre, which impairs or paralyzes its action 
and that of the nervi erigentes. 

Cases of psychical impotence are not uncommon, and are found 
more frequently in young men about the date of puberty, and 
much less commonly in men up to the fiftieth year. 

These cases present very many and widely different clinical 
pictures, while the one underlying symptom is the sexual weak- 
ness or impotence. 

It is not uncommon for young men who have lived chaste lives 
to find that at the first coitus they become so much excited that 
the penis does not become erect, and that it may even shrivel up. 
In some of these cases there may be partial erection and even a 
dribbling ejaculation. The result of this dismal failure varies in 
different individuals. Some men look at the matter calmly and 
philosophically, reason with themselves that they are sexually 
impetuous, and they wait and try again. Others (and they are 
in the majority) become very much depressed in mind and go 
post-haste to the surgeon. In all these cases it is usually found 
that a little good advice and wholesome common-sense will put 
the man's mind at ease, so that he can soon perform the function 
satisfactorily. But in many cases a sense of timidity or fear is 



PSYCHICAL IMPOTENCE. 79 

induced, which, for a long or short time, renders the man sexually 
weak or impotent. Such cases, if properly treated, can be cured. 

Some timid men of a retiring disposition remain for long periods 
absolutely continent, and then fear that their penis is not properly 
developed, or that their testicles are inactive, and as a result they 
become psychically impotent. 

Another class of cases of supposed impotence is found among 
young men who constantly see and fondle their fiancees, and who 
naturally become sexually excited. As a result, such a person 
notices that a few drops of clear mucus escape from the meatus, 
and that he may have queer but mild sensations in the penis and 
testes. In many of these cases the mind is not at all disturbed, 
but in some such is the sexual erethism and the impaired mental 
state that the man is unfitted for business and knows no comfort 
or pleasure. He feels certain that he is losing semen, and as a 
result of his worry, his erections, which usually occurred in the 
morning and in times of loving dalliance, are no longer present ; 
but the so-called spermatorrhoea, which is only an escape of 
normal mucous secretion (urethorrhcea ex libidine), keeps up. In 
this state of mind he dreads the thought of marriage, and feels 
certain that he cannot perform the sexual act. In many cases 
when the courtship is prolonged, and the courting seances are fre- 
quent and protracted, the lot of these young men is a very unhappy 
one. They are constantly and regularly exposed to a sexual 
erethism for which there is no legitimate relief at hand. After 
a time erections may not occur when in the company of his be- 
trothed, and they may or may not occur at other times. As a 
general rule, though erections are not experienced, the escape of 
mucus occurs at each loving interview, and there may be pollu- 
tions at night. Many young men thus tried remain steadfast and 
loyal, and by the help of the surgeon (and sometimes by the 
patience and tact of the wife) soon after marriage lose their fear 
and enter into normal sexual life. Others, however, are less 
scrupulous, and essay coitus with public women. In many cases 
that I have known these men have found relief, and have by 
practice convinced themselves that they were potent, and they 



80 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

became correspondingly happy. Many of these backsliding men 
I have known to become faithful and uxorious husbands and 
happy fathers of healthy children. Other men may have a less 
fortuitous experience. They resolve to test their sexual capacity 
with some other female, and when the critical moment arrives 
their morbid fear, increased, perhaps, by feelings of shame or 
remorse at their unfaithfulness, so preys on their mind that sexual 
desire is absent and erection does not occur. The result is that the 
man is still more unhappy, aud his fear troubles him incessantly. 
In many of these cases men have sexual desire and erections and 
perhaps emissions when away from their prospective brides. To 
some this evidence of sexual activity is very reassuring, but to 
others the irregularity and abnormality of the condition are a 
source of even greater dejection. Under the stimulus of kindly 
encouragement and by the aid of judicious advice these men sooner 
or later may enter into a happy matrimonial state. 

Many young men who have had more or less frequent and 
normal coitus before marriage, during courtship, become fearful 
that they may not be potent in the marriage-bed. They very 
often go with their doubts to the surgeon, who should always 
advise them to entertain no fear in their mind, and should posi- 
tively assure them that, notwithstanding they may have a few 
initial failures in their new relations, they will be competent. In 
some of these cases tonics and hygienic influences very often play 
a very useful part. 

We sometimes see cases in which nervous over-sensitiveness or 
religious scruples so act upon a man's mind that when he attempts 
coitus with a female he loses all desire and retires in disgust. 
Then, again, some young men are so fastidious, and perhaps so 
scrupulous, that they cannot associate, much less have sexual 
intercourse, with public women. In general these cases in time 
right themselves, but in some instances an abiding fear of sexual 
weakness or impotence is left which may prevent a man from 
contracting matrimony. In none of these cases is there anything 
seriously wrong, and a happy outcome can be induced if the 
patient be properly advised and judiciously comforted. As a 



PSYCHICAL IMPOTENCE. 81 

rule, marriage to a congenial helpmate soon leads to normal 
sexual contact. 

A goodly number of cases of sexual impotence are observed in 
young and even middle-aged men who are submitted to severe 
mental strain. In these cases there is usually an evidence of 
general ill -health, even of neurasthenia. Such men may be over- 
taxed in their professional duties (lawyers, civil engineers, mathe- 
maticians, etc.), or they, in their eager efforts to make money 
quickly, are continually in a state of excitement and doubt, which 
disturbs their whole economy. As a result, they may lose all 
sexual desire, and if they force themselves to coitus they experi- 
ence failure, or they may simply become sexually weak, and coitus 
is with them unsatisfactory and feeble in character. In cases in 
which the sexual organs were previously healthy this temporary 
disability ceases after a time, and the patient again becomes virile. 
AVhen, however, the sexual tract has been the seat of inflamma- 
tion (posterior urethra, prostate, ampullations, and seminal vesicles) 
the return to the normal state may be slow and halting. 

A large contingent of impotent young men is composed of those 
who have been addicted to long-continued masturbation and to 
sexual excesses. 

The impotence which follows in the course of masturbation is 
sometimes very difficult to cure, and amounts to what may be 
termed irritable weakness. These patients have so long practised 
this solitary vice that it is often difficult to (as one may say) 
switch them off into natural habits. Xot only do they, in many 
instances, become averse to intimate relations with a woman, but 
they experience a sense of shame, and are very fearful that they 
will fail in coitus. Such men frequently have nocturnal pollu- 
tions, which have a very damaging effect upon them mentally. In 
these cases there is very frequently more or less damage to the 
deep sexual parts, and as a result the disability is more pronounced. 

In very many cases of impotence incalculable harm is done the 
patient by the mendacious exaggerations of quacks ; but this bad 
effect is especially well marked in psychically impotent men who 
have practised masturbation. 

6 



82 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

Sexual excesses naturally lead to reaction in which the sexual 
desire is much less keen than formerly. This condition very often 
preys on the patient's mind, and he fears that he has lost his virility. 

It is natural in these cases for a condition of sexual inertia to 
ensue, but except in very bad cases sexual power is not wholly 
destroyed. Rest and general hygiene usually bring the men out 
of their slough of despond. 

Men apparently vigorous in mind and body and of more advanced 
age sometimes consult the surgeon for very insufficient reasons. 
They have had one or several attacks of gonorrhoea, perhaps, many 
years before, which in their cases have left no damage to the urethra 
and prostate, but lately they had convinced themselves that their 
sexual capacity was less vigorous than formerly, and that it must 
be due to their old trouble. In many of these cases the real con-, 
dition is one of less keen sexual appetite and vigor, caused, in 
many cases, by mental and physical overtaxing, than was pos- 
sessed in earlier years. 

The psychical effects of varicocele in inducing impotence are 
described in Chapter XX. 

As a rule, most men suffer from psychical impotence at some 
period of their life for a longer or shorter time. Seeing that the 
mind exerts such a far-reaching and controlling influence on the 
sexual act, it can be readily understood that in the multiplicity 
of disturbing causes which may operate on the brain a temporary 
impotence may be induced. Pleasant conditions and surround- 
ings are absolutely necessary for normal sexual contact, and when 
in any manner these are disturbed the function is either interfered 
with or held wholly in check. Thus, a man may be disturbed 
by ominous sounds, by unpleasant odors, by the necessity for 
haste, and by fear of discovery. Certain physical defects in the 
woman may abort all sexual desire. There may be a flabby vulva, 
or a very large vagina, laceration of the perineum, or great red- 
ness of the vulva, or the presence of a purulent discharge. Ex- 
cessive obesity in the female in many instances has been known 
to cause irremediable impotence of the male consort. Warts or 
red or eczematous patches in and about the labia majora and minora 



PSYCHICAL IMPOTENCE. 83 

have been known to cause a sudden inhibitory effect. The fear 
of contracting a venereal disease often puts an end to the attempt 
of a man at coitus with a public woman. Then, again, a man 
may be indifferent or may feel a repugnance to a woman, or a hus- 
band may entertain a suspicion as to the fidelity of his wife. All 
these conditions may produce a disturbing effect on the brain and 
sexual centre. 

In some cases the loss of a beloved wife or mistress so preys 
on a man's mind that for a time he has an aversion to the female 
sex, and he may be temporarily impotent. Cases have been 
reported in which men, in order to perform vigorous coitus with 
a woman to whom they were rather indifferent, have had to fix 
their minds during the act upon the voluptuousness of another 
and highly-prized consort. Many men are very vigorous with 
some women and can have only unsatisfactory coitus with others. 
Alcoholics, as a rule, stimulate the brain and sexual centre, and 
in cases of psychical impotence they (as we may say) " help many 
a lame dog over the stile." A case, however, has been reported 
in which a drunken man failed to copulate with a woman of the 
town, and when informed of the fact he was so depressed that for 
a time he was impotent. A curious case is on record of a man who 
had normal coitus with other women, but could only cohabit with 
his wife when he was much enraged. Many women have little 
sexual desire ; to some sexual contact is unpleasant and even 
revolting ; while others reluctantly consent to it, and wonder at. 
their husband's carnal lust. Such frigidity on the part of the 
wife naturally reacts powerfully on the husband, who may become 
sexually weak or even impotent. 

Some men have a predilection for certain women ; one likes a. 
blonde, another a brunette, while still others yearn for a fiery 
auburn consort, and none of these men can have full and satis- 
factory sexual intercourse unless congenially mated. 

We occasionally meet with cases in which there exists what 
may be termed sexual apathy, due, perhaps, to some condition of 
the brain and sexual centre. In all of these cases (and I have 
seen fully a dozen) the virility of the man has never been up to 



84 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

the standard of normal development. As boys they may or may 
not have masturbated for a few times and generally at long inter- 
vals, and very often as a result of curiosity inspired by other 
boys. At and after puberty they may have infrequent sexual in- 
tercourse, which gives them little or no pleasure ; then the sexual 
desire ceases, and they bother themselves no longer with the 
matter. In most of these cases the patients are hard workers 
mentally or physically, or in both directions, but they never 
become melancholic. 

A number of very interesting cases of psychical impotence 
have been published in medical literature. A peculiar case is 
reported of a gentleman who, while on a visit to the country, was 
seduced by a lady in full walking costume. During a period of 
one year he continued to cohabit with the same woman, under 
similar conditions. He later on married an estimable and healthy 
woman, and though in the full exercise of all his mental and phys- 
ical powers, he was unable to begin or even to complete the act. 
His previous intercourse with a woman in full dress had disturbed 
his equilibrium so much that he could not perform the act until 
his wife had her clothes on. 

In striking contrast with the foregoing case is that of a man 
who for years had had coitus successfully when in the seclusion 
of his bed-chamber and without the accompaniment of dress. On 
several occasions he endeavored to perform the act both with a 
mistress and later with his wife when dressed, and he failed dis- 
mally every time. 

A remarkable example of psychical impotence was observed 
in the case of a prominent mathematician who married a lady 
congenially suited to him. Both were in perfect health and de- 
sired children, yet at every attempt to complete intercourse some 
abstruse problem would force itself into the mind of the professor 
and destroy at once all capacity for the performance of the act, so 
that he was compelled to give up the attempt. Again and again 
the same accident occurred. It seemed utterly impossible for him 
to control his mind in the matter of mathematical problems suffi- 
ciently long to accomplish anything. The family physician finally 



PSYCHICAL IMPOTENCE. 85 

counselled him to get partially under the influence of alcohol and 
then try. He took the advice, and was enabled to reach the 
desired goal without any further trouble. 

A case is on record of a man who was much enamored with a 
lady whose right leg had been amputated at the thigh. He always 
had satisfactory coitus with this person, but was entirely impotent 
with perfectly formed women. Later on in life it was always 
necessary to his sexual gratification that he should have a consort 
who had only one leg. 

It is a matter of history that a man, at other times perfectly 
virile, who had been a member of the volunteer fire department, 
was never able to have coitus at night, for the reason that when- 
ever he went to bed it was with the expectation that he would 
have to go to a fire. 

On this subject Howe 1 says : " Even in persons of vigorous 
health, psychical impotence may result from fear. Impotence 
has been produced in a healthy man by a friend's recital of his 
own surprising failure. The thought of the accident that befell 
the friend occurred at the time of intercourse, and he, too, failed. 
A married patient of mine, a lawyer, with excellent physique, the 
father of two children, became temporarily incapacitated in this 
way : Reading in a medical journal that impotence might attack 
healthy persons, temperate in all things, and without notice, he 
became impressed with the fear that a similar accident might 
befall himself. Curiously enough, the next time he attempted 
intercourse the fear took complete possession of him, and he 
became temporarily impotent." 

Finally, there is a class of cases of men who are temporarily 
impotent for the reason that they have got out of practice. Thus, 
a husband is away for a long period from or loses a beloved wife, 
and for a time so cherishes her memory that his sexuality is dor- 
mant. Or a man may lose a very congenial mistress, and for a 
time sexual desire seems extinct. Then, again, for various causes? 
some men suddenly cease to have sexual intercourse, and for a 

1 Excessive Venery, etc. , p. 85 et seq. 



86 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

longer or shorter \ time are much occupied mentally or are greatly 
worried. In these cases very often a feeling of doubt and timidity 
is developed, and the man refrains from sexual intercourse. Accord- 
ing to my observation, in the course of time most of these men? 
when not very old, find congenial females as wives or consorts, 
and then the supposed sexual incapacity soon gives way to gratify- 
ing vigor. 

The prognosis in these cases is good. 

Treatment. In all cases of psychical impotence the surgeon 
should seek out the cause and then give directions as to its removal. 
Patients thus affected need kindly advice, encouragement, and a 
plain statement of the exact facts in their case. They should be 
firmly assured that they are in no danger of losing their virile 
power, and that they must under no circumstances give way to 
doubts and dreads. 

In the cases of men who become much excited and have a 
mucous discharge while near or fondling women, speedy marriage 
should be recommended. It is always most important that ex- 
cesses in coitus should not be indulged in, and that when the act 
is performed the surroundings should be pleasant and satisfactory. 

Good hygiene, avoidance of exposure to sexual excitement, 
plenty of fresh air, out-door exercise, and wholesome food, will 
contribute largely to the patient's well-being. In many cases 
relief from all business cares and occupations, with entire relaxa- 
tion, is productive of great benefit. According to indications, 
massage, cold douches, salt-water bathing, electricity, and stupes 
may be employed 

Iron, quinine, coca, kola, arsenic, and the animal extracts may 
be used when the necessity for them is indicated. In some cases 
tincture of cantharides (10 to 15 drops three or four times a day) 
has seemed to be very beneficial. With due restraint as to inor- 
dinate alcoholic indulgence, it may on occasions be necessary to 
stimulate a man's flagging energy by means of whiskey, brandy, 
champagne, or Burgundy. 

In all cases it is incumbent on the surgeon to carefully explore 
the whole genital tract, in order to ascertain whether any part is 



PSYCHICAL IMPOTENCE. 87 

in a morbid condition. This examination should be very thorough 
and the condition of the meatus, urethra, prostate, seminal vesicles, 
and ampullations should be clearly ascertained. In addition, a 
thorough examination of the bladder, anus, and rectum should 
be made. 



CHAPTEK VII. 

SYMPTOMATIC IMPOTENCE. 1 

In a considerable proportion of cases of impotence certain 
morbid conditions of the end of the penis, of the bulbous urethra, 
of the prostatic urethra, and prostate gland, and perhaps of the 
seminal vesicles, so react on the sexual sphere that a condition of 
diminished vitality and function is induced. Unfortunately, in 
these cases we possess no facts derived from the post-mortem 
study of the conditions of the sensory sexual nerves or of the 
sexual centre. 

Our knowledge of the morbid changes in the sexual tract is 
quite full and tolerably clear, but how these changes operate 
on the nerves and the spinal cord centre, and what structural 
conditions they produce, are mysteries to us 

Whatever the morbid change may be the effects in many cases 
are very apparent, and the thought suggests itself that some tem- 
porary damage has been done to the sensory nerves or the sexual 
centre by which their function is more or less impaired. 

Impotence being symptomatic of the above-mentioned well- 
defined morbid conditions of the sexual tract, it seems to me 
more natural to designate this disability as symptomatic impo- 
tence rather than as atonic impotence — the term which is used 
by several authors. 

We are certain as to the symptoms, but we do not know about 
the atony. A clear and systematic presentation of this subject 
can only be given by adopting an anatomical basis by which the 
various sources of irritation may be studied seriatim, and their 
effects may then be lucidly traced. 

1 See also Chapters XVI., XVII., and XVIII. 



SYMPTOMATIC IMPOTENCE. 89 



PERIPHERAL IRRITATION. 

Impairment of the sexual function, even to the extent of de- 
cided impotence, may be due to congenital and acquired malfor- 
mations of the prepuce and glans penis. The following case 
presents interesting features : 

A man, twenty-six years old, who had never had gonorrhoea, 
and who had practised masturbation very slightly, was married 
to a very attractive and congenial lady of his own age. During 
a period of six months the man had many times indulged in coitus, 
which on no occasion was satisfactory. His erections were at first 
nearly normal, but ejaculation was always premature, and the 
sexual act was never completed. This state of affairs went on 
until just before the patient consulted me. He was then very 
much worried, and physically was below par. Examination of the 
urethra, prostate, and seminal vesicles showed these parts to be in 
normal condition. But the condition of the distal part of the 
penis demonstrated the cause of the trouble. The prepuce was 
long and tight, and its orifice, which was very much reddened, 
was abnormally small. When by some force the prepuce was 
retracted a reddened, pouting condition of the meatus was found, 
which extended into the urethra. The glans penis was red and 
very tender. The diagnosis of extreme peripheral irritation of 
the penis was made, and circumcision was, with the patient's con- 
sent, performed. Within six weeks erections became normaland 
coitus was satisfactorily indulged in. In this case there was not 
any subsequent impairment of the sexual power. 

I have seen several cases in which erections were flabby and 
ejaculations were premature, which resulted from adherence of the 
prepuce, which had existed from birth and which gave rise to 
venous stasis of the prepuce and glans. 

In like manner I have several times seen a short, fibrous frse- 
num, with long, tight prepuce, give rise to symptoms which con- 
vinced the patient that he was impotent. Smallness of the meatus, 
both congenital and acquired, from chancroidal or syphilitic ulcera- 



90 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

tion, not infrequently, in my experience, has caused such impair- 
ment in the commencement of the sexual act that its full per- 
formance became impossible. In this connection it is well to add 
that in the case of a nervous young man who had a halo of soft, 
small vegetations in the coronal sulcus, such was their tenderness 
that on intromission of the penis the erections instantly ceased 
and ejaculations took place at once. 

As a rule, cases of partial or complete impotence, due to these 
malformations of the penis, are promptly cured by operation, and 
the probable existence of these causes shows how important it is 
in every case to carefully examine the virile organ. 

In these cases just considered there may be little or no mental 
suffering, or the patient's condition may give him serious concern. 
But, as a rule, operation gives such prompt and decided relief 
that mental depression is soon dispelled. 

Unfortunately, in some of these cases of irritation of the pre- 
puce and the glans there is a history of early, energetic, and long- 
continued masturbation, which has caused chronic congestion in 
the posterior urethra, together with emissions and imperfect erec- 
tions. In these cases relief is sometimes somewhat slow in coming 
on, and, besides operations on the prepuce and glans, careful treat- 
ment of the urethra is necessary. 

It happens, though quite rarely, in some of these cases that a 
condition of morbid fear remains for some time, which prevents 
normal coitus ; but cheering and comforting advice, supplemented 
by tonics, fresh air, and sea and cold baths, generally tend to 
restore the confidence and virility of the patient. 

CHRONIC BULBOUS URETHRITIS AND STRICTURE. 

Chronic inflammation of the bulbous urethra alone furnishes 
quite a large contingent of sexually weak and impotent men. 
These patients may or may not have been addicted to masturba- 
tion and sexual excesses. They usually give a history of an early 
and severe attack of gonorrhoea, followed by a more or less per- 
sistent gleet, and perhaps other attacks of gonorrhoea. They are 



SYMPTOMATIC IMPOTENCE. 91 

usually men between thirty and fifty years of age, and they pre- 
sent themselves with a history of waning erections, premature 
ejaculations, and lessened desire. Many of these men say that 
their attention was first called to the disturbed sexual function by 
their inability to promptly produce normal ejaculations. The 
sexual act in these cases is at first somewhat prolonged, and this 
dilatoriness gradually becomes more pronounced. Then deficiency 
in erection is noticed, together with feeble, flabby, and perhaps 
premature, ejaculations and very often nocturnal emissions. I 
have many times been much surprised at the patience and equa- 
nimity with which these patients regarded their disability. In 
my experience in this particular class of cases mental worry is 
not often observed, and sexual neurasthenia is very exceptional 
indeed. 

In many of these cases we find submucous cell-infiltration 
around the bulbous urethra, which may be contracted to 25 or 
even 20 of the French scale. In some cases the new cell-forma- 
tion is soft and succulent ; in others it is more dense. I have 
very many times carefully examined these cases as to the condi- 
tion of the anterior and posterior urethra, and found that the 
morbid process was localized in the bulbous urethra, and that the 
prostate and seminal vesicles were healthy. 

As a rule, these patients can be benefited and cured if they will 
refrain from sexual excitement and excesses in other directions 
than coitus, but not otherwise. 

A more pronounced class of cases is seen in men who have true 
stricture at the bulb. The less severe class of cases is found, as a 
rule, in men about thirty to thirty-five years of age, in which the 
stricture tissue is not, as yet, very firm and dense. The severer 
form includes those cases in which much fibroid infiltration, even 
to the extent of nodulation, is present. 

In many of these cases, before the difficulty in urination is ex- 
perienced, or when it is very slight and mild, the patients begin 
to experience the same sexual debility that sufferers from chronic 
bulbous urethritis complain of, as we have already seen. In this 
condition gradual dilatation is indicated, and, if well borne, with 



92 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

the increasing size of the canal improvement in sexual desire and 
power is induced sometimes in a surprising degree ; but in some 
men, particularly those in whom the sexual appetite has never 
been very active, the desire and power in coitus return slowly 
and with halting intervals. When the stricture is very dense 
and tight the return of sexual activity may be quite slow ; but, 
in general, a guardedly favorable prognosis may be ventured. 

When the stricture is very small an impediment to the escape 
of semen is produced, and then, in addition to impotence, the 
patient is aspermatous. 

CHRONIC BULBOUS AND POSTERIOR URETHRITIS. 

Chronic inflammation of the bulbous and posterior urethra is 
a not uncommon cause of sexual weakness and impotence. This 
condition is well shown in the following case : 

A man, aged thirty-two years, thin, nervous, and somewhat 
worried, had masturbated from his seventeenth year until shortly 
before his marriage, two years previously, having had gonorrhoea 
in a mild form and of short duration when he was twenty-four 
years old. Several months before the ceremony he began to suffer 
from emissions, which occurred several times a week. He found 
coitus impossible, though he had partial erections in the morning. 
Physical examination showed intense congestion of the bulbous 
and prostatic urethra, with considerable thickening of the former 
and a scanty mucopurulent secretion. Rectal examination of the 
prostate gave no results. By the careful use of moderate-sized 
sounds, beginning with one of calibre 24, French scale, chilled in 
ice-water, and nitrate of silver instillations, together with hygiene 
and tonics, this unpromising case slowly improved. At first the 
erections were not perfect and were of short duration, but later 
on they became normal. 

As a rule, cases of sexual debility like the foregoing, in which 
the bulbous and posterior urethra is involved, are quite refractory 
to treatment, and they demand much care and attention from the 
surgeon. 



SYMPTOMATIC IMPOTENCE. 93 

CHRONIC BULBOUS AND POSTERIOR URETHRITIS 
WITH PROSTATITIS. 

A more advanced class of cases is sometimes observed in which 
the bulbous and posterior urethra, as well as the prostate, is in- 
volved. This combination and its effects are well shown in the 
following case : 

A man, aged thirty-two, of good physique and sound mind, 
had indulged freely, and at times excessively, in sexual inter- 
course since his eighteenth year. He had mild gonorrhoea when 
twenty years old, and again when twenty-eight. For two years 
prior to his first visit to me he had noticed a small mucopuru- 
lent globule at the meatus every morning, and had felt an uneasy, 
dull, burning pain in the perineum and near the anus. There were 
increased frequency of urination, and moderate discomfort at the 
end of the act. His sexual desire and activity had been going 
from bad to worse for a year. The first jet of urine contained 
threads of pus, mucus, and epithelium. Examination of the 
urethra revealed great tenderness in the bulbous and prostatic 
portions, with so much thickening of the walls as to hug quite 
firmly a bougie a boule, No. 25, French scale. The prostate was 
somewhat enlarged and tender in all directions, particularly on 
the left side, and after massage a milky, mucoid fluid peculiar to 
chronic tubular prostatitis escaped from the meatus. In this case 
cold sounds of increasing size, with nitrate of silver instillations, 
alternating with moderate lavage of the posterior urethra with a 
solution of permanganate of potassium (1 : 2000), cured the local 
process, and coincidently the sexual function became more vigor- 
ous until the normal standard was reached. 

In the foregoing case there was only a moderate amount of 
mental uneasiness regarding the urethral and sexual troubles. In 
some of these cases, however, the mental trouble is quite severe, 
and in exceptional instances true sexual neurasthenia is observed. 



94 SEXUAL DISORDERS OF THE MALE AND FEMALE. 



CHRONIC POSTERIOR URETHRITIS. 

Cases of sexual debility and of impotence are sometimes observed 
in which the underlying morbid process is seated in the posterior 
urethra, and in which the prostate itself is not involved. Post- 
mortem examinations have clearly shown that gonorrheal inflam- 
mation may be strictly limited to the epithelium and the submucous 
connective tissue layer of the posterior urethra — notably that por- 
tion covering the venimontanum. I have carefully examined the 
urethra and the urine of very many cases in which all signs pointed 
to posterior urethral involvement alone, and the most thorough 
examination of the prostate by the aid of the finger in the rectum 
failed to reveal any evidence of disease. To further confirm the 
diagnosis, the urine passed after the prostatic massage was micro- 
scopically examined, and the characteristic tissue elements and 
phosphatic salts were not found. I am thus emphatic and precise 
in details, for the reason that there is a tendency on the part of 
some writers to ascribe all symptomatic (or, as they term it, atonic) 
impotence to lesions of the prostate, and to deny to posterior 
urethritis any pathogenic influence. 

Cases of sexual debility and impotence in which chronic poste- 
rior urethritis is found as the probable morbid factor, present, as 
a rule, the symptoms peculiar to that disease. Such patients give 
a history of gonorrhoea which has left in its wake a tendency to 
frequent micturition, with, perhaps, more or less uneasiness at the 
end of the act. In some cases there is, besides, a history of recur- 
rent slight hematuria ; in others, of a sensation of deep pelvic 
and rectal uneasiness. Some of these patients have noticed that 
their urine, particularly that which is first passed in the morning, 
contained gonorrheal threads. In these cases the development 
of the sexual debility is usually slow, and it begins with feeble 
erections, protracted sexual act, and dribbling and perhaps pre- 
mature ejaculations, without or with a diminution in the intensity 
of the customary orgasm. Beginning in this manner the disability 
becomes more or less pronounced until an impotent state is reached. 



SYMPTOMATIC IMPOTENCE. 95 

Patients who suffer from this form of impotence are usually 
men of thirty years and beyond — even to fifty years. It is 
sometimes seen in men between the ages of twenty and thirty. 

As a rule, this form of impotence is more or less promptly 
relieved by treatment ; and although some men suffering from it 
become worried and dejected, and even neurasthenic, in my ex- 
perience they, in general, regard the matter quietly and philo- 
sophically, and aid the surgeon in his efforts to cure them. 

Many of these patients have been guilty of sexual excesses, and 
such subjects should be made to clearly understand that a return 
to their old practices will be followed by more permanent impo- 
tence. 

Knowing, as we do, that so many sensory nerves end in the 
verumontanum, and that this part is so constantly and severely 
involved in chronic posterior urethritis, the question suggests 
itself : whether this form of impotence is caused by the irritation 
of the ends of these nerves, which is conveyed backward to the 
sexual centre, and there, after a period of excitation, produces a 
condition of sedation? 

CHRONIC PROSTATITIS. 

A very large proportion of the cases of symptomatic impotence 
are found in men who are suffering from chronic prostatitis. In 
almost all of these cases the disease of the prostate has been caused 
by early and long-continued masturbation, by sexual excesses, by 
sexual excitement without natural relief, by coitus reservatus, and 
as a result of gonorrhoea. 

The patients suffering from this form of impotence may be 
young (and they are in the majority), middle-aged, or old. They 
complain of various conditions of disability — namely, of lack of 
desire (and in some impetuous desire), of imperfect erections or 
absolute want of erections, of feeble and protracted coitus, or of 
premature ejaculations. They often have nocturnal emissions, and 
some have fairly good erections when they are not near women, 
but these usually fail them when they come to close quarters. 



96 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

Young men in particular who are thus affected constitute the 
large army of sufferers from so-called spermatorrhoea. They 
complain that their semen escapes either after urination and defe- 
cation, and during severe physical exercise, or involuntarily. In 
many of these cases, particularly in young and middle-aged sub- 
jects, there are observed mental worry, hypochondriasis, and even 
neurasthenia. 

Many of these cases are very amenable to treatment, others 
yield less readily, while not a few are very refractory. In some 
cases intense sexual erethism is very persistent and damaging in 
its effects. Such patients may endeavor to force themselves to 
coitus, and usually fail, or they may subject themselves to sexual 
excitement, or to unnatural practices, and always with bad effect. 
It is only necessary here to give this general outline of what we 
may call prostatic impotence, and to refer the reader to the chapter 
on Chronic Prostatitis for more minute details as to the varieties 
of cases and their symptoms. 

INFLAMMATION OF THE SEMINAL VESICLES. 

There is a tendency nowadays to ascribe many cases of sexual 
weakness and impotence to inflammation of the seminal vesicles, 
and to deny that the prostate is in any way a pathogenic factor. 
In order to gain true and clear views as to the probable influence 
of spermato-cystitis on the sexual functions, I have made many 
observations and examinations, and have supplemented them by 
long-continued and extended microscopical study of the urine, of 
the semen, and of abnormal discharges from the urethra in these 
cases. These studies have been unbiased by any theory, and have 
not been prejudiced by any peculiar ideas or views ; my aim has 
been not to theorize, but to put a proper interpretation on the facts 
carefully elicited and the appearances presented. As a result of 
extended observations and close study, I am led to believe that 
disease in the seminal vesicles is rather rare, and that seminal 
vesiculitis plays a subsidiary role in the production of impotence. 
It is rather uncommon to find any trouble beyond the prostate in 



SYMPTOMATIC IMPOTENCE. 97 

young and impotent men, particularly in masturbators and those 
who have not suffered from chronic gonorrhoea ; and if the seminal 
vesicles seem involved, it is only as a concomitant, or, perhaps we 
may say, a complication of chronic prostatitis. In a number of 
middle-aged men, and in some past fifty years of age, who have 
suffered from impotence, I have found direct evidence of chronic 
inflammation of the seminal vesicles, but in every case there was 
unmistakable evidence, either on rectal palpation or in the micro- 
scopic examination of the expressed secretion, that the prostate 
was also the seat of disease. In the light of my present experi- 
ence I am led to think that in some (not numerous) cases of mas- 
turbation and gonorrhoea in young impotent men the prostate and 
seminal vesicles are involved, but that in general this symptom- 
complex is found in men of forty years of age and beyond, who 
have been masturbators, have had chronic posterior urethritis, 
and who throughout life have been very vigorous sexually or have 
indulged to excess and perhaps abnormally. In this restricted 
manner I am disposed to look upon seminal vesiculitis as a cause 
or factor in the development of symptomatic impotence. 

It must be remembered that in this chapter only a general sur- 
vey of the subject of symptomatic impotence is given, but that it 
is further fully elaborated in the matter of clinical history and 
treatment in Chapters XVI., XVII., and XVIII., to which the 
reader is referred. 



CHAPTEE VIII. 

ATONIC IMPOTENCE. 

Sexual weakness and even impotence are not uncommonly 
complained of by patients who have suffered from various ady- 
namic diseases and by those afflicted with brain or spinal-cord 
diseases, and they are said by some authors to be more or less 
remotely caused by the action of a number of drugs. 

This form of impotence has been described by some authors as 
symptomatic impotence, but I think the term atonic impotence 
is more correct, for the reason that in these cases there are im- 
paired nervous function and stimulus, due to devitalizing causes, 
brain and spinal cord lesions, and the depressing action of drugs. 
In all cases the underlying cause is the atonic state of the brain, 
spinal cord, and sexual centre. 

In the various forms of anaemia such is the general lowered 
standard of the vital processes and of metabolism that the func- 
tion of no organ is perfectly performed, and with the resulting 
depression to . the cerebro-spinal system the sexual function is 
more or less torpid, and it may even be temporarily extinguished. 
En neurasthenia the supply of nervous force required for the essen- 
tial vital functions (chiefly circulation, respiration, and alimenta- 
tion) is so much drawn upon that none is left for a function like 
that of copulation, which is only occasionally called into use, and 
can, without detriment to the patient, be absent or in abeyance for 
varying periods. After diphtheria, erysipelas, influenza, typhoid 
fever, pneumonia, rheumatic fever, and in the course of malaria 
and uraemia, sexual weakness, more or less pronounced, is often 
observed, and the question suggests itself to one's mind whether 
the underlying cause is the impaired or depressed nutrition of the 
nervous centres or whether the toxemic condition incident to these 
diseases is the essential cause ? 



ATONIC IMPOTENCE. 99 

Many persons who suffer severely from gastric and gastro- 
intestinal disorders are not infrequently weak sexually, and their 
impotent condition is readily explained by the malnutrition, which 
produces nervous atony, which in itself is increased by the worry 
incident to these affections. 

In some cases of diabetes a well-marked and even permanent 
state of sexual impotence may be produced, being sometimes a 
first and premonitory symptom, caused, in all probability, by the 
general bad state of nutrition of the patient. In some of these 
cases, coinciding with the diminution in the amount of sugar in 
the urine and the general improvement in health (when it occurs), 
the sexual function may become more or less active. With the 
severe development of the general systemic disorder this function 
soon becomes less active, and then perhaps extinct. 

In many functional and organic affections of the brain a more 
or less complete and permanent form of impotence is sometimes 
seen. In cases of cerebral excitement and exhaustion from various 
causes, of spinal irritation, cerebro-spinal meningitis, spinal menin- 
gitis, syphilis of the brain and spinal cord, myelitis and locomotor 
ataxia, the abatement of sexual power is soon seen, sometimes after 
a period of great erethism, and in the course of time it is entirely 
destroyed. 

Sexual excess, and particularly the indulgence in abnormal 
coitus, very often produces atonic impotence by their damage to 
the general nervous system and the sexual centre. The same 
may be said of excessive masturbation. 

It is not uncommon to observe patients who suffer from atonic 
impotence who may be said to be sexually worn-oat. Such 
patients may or may not have had gonorrhoea or syphilis, but 
were in their early days virile and persistent in sexual inter- 
course. Living, as they usually do, a fast life, they keep late 
hours, drink and smoke to excess, and are in many instances im- 
moderately given to sexual excesses in unnatural methods (chiefly 
coitus ab ore), and also naturally. Toward forty-five and fifty years 
of age (and sometimes earlier) these men begin to decline in sexual 
power (in some the retrograde process is slow, in others rapid), 



*f C. 



100 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

and, as a rule, in spite of careful treatment and general reforma- 
tion, they lose desire and power until the end is reached in utterly 
incurable impotence. 

An old, persistent syphilitic dyscrasia, in combination with 
alcoholism and the indulgence in sexual excesses, leads in many 
instances to permanent impotence. 

It is said that in the East Indies there is scarcely a virile man 
over twenty-five years of age. The sexual decay in these men is 
due to the practice of long-protracted coitus. While in the act 
they keep ready at each hand a basin of cold water or some cold 
object, with which they constantly cool their hands just before the 
orgasm comes on. In this way they greatly prolong the sexual 
act, and in so doing wear out their sexual centre and perhaps 
damage other nervous parts. 

In America the unnatural prolongation of coitus (for the alleged 
reason of greater gratification to the female) is very often the cause 
of a more or less persistent form of atonic impotence, and also of 
neurasthenia. 

In chronic morphine- and opium-addiction loss of sexual desire 
and power is an early result, and it remains as long as the use of 
the drug is continued. 

Bromide of potassium has been claimed as a frequent cause of 
sexual weakness and decay, but our knowledge of its action in 
this direction does not rest on a solid basis. Cases undoubtedly 
have occurred in which it seemed probable that the long-continued 
use of the drug had impaired the sexual function, but sufficient 
prominence has not been given to the morbid conditions for which 
the therapeutic agent was administered and to the probable 
anaphrodisiac influence of these morbid states. It is very prob- 
able that decline in the sexual function may follow the long- 
continued use of this drug in a healthy individual, for the reason 
that it acts as a sedative to the sexual organs, but on this point 
we have no reliable information. 

Large and long-continued doses of iodide of potassium are said 
to cause atrophy of the testes and sexual impotence. Here, again, 
do distinction is made between the action of the drug and the 



ATONIC IMPOTENCE. 101 

affection for which it is administered. While, therefore, it is 
probable that iodide of potassium may, when used for long periods, 
cause diminution in a man's virility, we have not to-day sufficient 
trustworthy evidence to prove the point. 

Alcoholic excesses at first increase the sexual desire, but later 
on this stimulant ceases to stimulate, and it produces an obtunding 
and devitalizing effect on the nerves of generation. 

In chronic lead-poisoning sexual impotence is said to be a quite 
constant and prominent symptom. The use of camphor and tur- 
pentine is said to produce an anaphrodisiac effect. It is claimed 
that excessive use of tobacco and cigarettes may cause sexual 
torpor and inability, and if it does, it is by reason of the depress- 
ing effect of the poison on the nervous centres. 

The excessive use of coffee and absinthe has been cited as a 
cause of impotence, but it should be remembered that when such 
claims are made full details of the alleged cases are absolutely 
necessary. 

Nervous impressions transmitted to the sexual centre from the 
testes undoubtedly have much influence upon the sexual function, 
although our knowledge of its action is very limited. Structural 
affections of the testes and the vasa deferentia may lead to 
azoospermatism, and it is very probable that when mild or severe 
morbid changes take place in these organs a depressing effect is 
produced in the spinal cord and the sensory nerves. In cases of 
exhaustion, of overwork, and of adynamic disease the structural 
vitality of the testes is much interfered with, and it is probable 
that the nerve impressions conveyed to the body under these 
circumstances in a greater or less degree produce a condition of 
sexual torpor or impotence. This point is worthy of careful 
thought. We have become so accustomed to look for causes of 
impotence in the sexual tract itself that we really pay little heed 
to the probable depressing effects of testicular troubles upon the 
central nervous system. 

In the newly proposed operation of castration for prostatic 
hypertrophy the fact has been clearly brought out that in some 
cases the removal of the testes is followed by mental depression 



102 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

and unbalancing, as if a normal stimulus had been suddenly with- 
drawn. This fact suggests to us that very probably in health and 
disease some indeterminate impressions are conveyed from the 
testes to the central nervous system which are necessary to its 
full integrity. 

Sexual vigor usually grows less active with the advancing age 
of the patient, in some men earlier than in others. Such cases are 
generally due to sexual inertia, particularly to gradual exhaustion 
of the sexual centre. They are really cases of senile atonic im- 
potence. 

Treatment. As atonic impotence is only one of many symp- 
toms incident to anaemia and various other adynamic conditions, 
brain affections, and chronic systemic poisoning, the first indica- 
tion is to determine what is the morbid factor, and when discov- 
ered to treat it on general medical principles. 

In some of these cases much mental and perhaps some physical 
benefit may follow the judicious instillation of strong nitrate of 
silver solutions (of strength varying from 1 to 5 per cent.) into 
the prostatic urethra. Likewise the passage of a warmed sound 
once a week or more frequently may be of benefit. 

Damiana has failed to prove an efficient aphrodisiac remedy, 
and cantha .rides is so irritating to the stomach and the urinary 
tract that, as a rule, it cannot be given in sufficiently large doses 
to excite the sexual centre. In some cases, however, it seems to 
act beneficially on the sexual centre. 

In some cases much benefit is produced by the ingestion of a com- 
bination of atropine and strychnine. The initial dose of atropine 
is one one-hundredth of a grain in water three times a day, and 
that may be increased to one-sixtieth or one-fiftieth of a grain. 

The usual dose of strychnine is one-thirtieth of a grain, which 
may be gradually and continuously increased to one-twentieth of 
a grain. 

Quinine in three-grain doses, given three times a day, par- 
ticularly in combination with strychnine, and in very atonic 
cases with atropine, is sometimes of markedly beneficial effect. An 
excellent preparation is the following : 



ATONIC IMPOTENCE. 



103 



B 


— Ferri et quininae cit. 
Fl. ext. cocas 
Tr. gentianae co. . 
Tr. nucis vomicae . 










. 




3«j- 

gtt. ccc. 






Aquae . 
One teaspoonful in a win? 
meals. 


glass of watei 


- three 


. 3S..-M. 

times a day one 


hour 


after 



And the following prescription, taken in the same dose and 
manner, may be administered : 



R. 


— Quiniae sulph. 


. gr. lxiv to xcvi 




Tr. ferri muriat. . 


gtt. cccxx. 




Tr. nucis vomicae . 


. gtt. ccc. 




Syr. simple . 


• • • • lij- 




Aquae .... 


q. s. ad |jiv. — M. 



A preparation composed of various animal extracts, known as 
phospho-albumin, acts as a decided sexual tonic in some cases. 

Chloride of gold and sodium, administered in the form of 
pills, in doses of one-twentieth of a grain three times a day, have 
been vaunted by several authors as having marked aphrodisiac 
power. 

Phosphorus proves to be in many cases of anaemia and atonic 
sexual exhaustion a most effective remedy. It is best given in 
gelatin-coated pill form, the initial dose being one one-hundredth 
of a grain three times a day, and the dose may be gradually and 
cautiously increased to one-twentieth of a grain. Care as to the 
condition of the stomach must be exercised in cases where this 
drug is taken. 

Phosphide of zinc, in doses of one-tenth of a grain three 
times a day, may be given. 

Nutritious and easily digested food should be taken, together 
with a moderate amount of Burgundy or claret. 

Many local remedies act well as general and local stimulants 
in atonic impotence. Cold sitz baths and cold affusions to the 
penis, testes, and lumbar region, carefully administered or used, 
may often prove very invigorating. Systematic cold bathing and 
salt-water bathing in combination with active internal medication 
should be employed in all cases. Mental relaxation, physical rest, 



104 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

fresh air, change of scene, together with moderate ont-door exercise, 
should be insisted upon, provided they are practicable. Massage 
moderately administered and local and general faradization may 
produce excellent stimulant effects. 

If any affection of the meatus, urethra, prostate, seminal 
vesicles, or testicles be present it should receive proper atten- 
tion. 



CHAPTEE IX. 

OEGANIC IMPOTENCE. 

Many cases of impotence depend on certain structural defects, 
anomalies, changes, and distortions of the penis, which are of con- 
genital or acquired origin. 

In many cases of malformation of the penis coitus is impos- 
sible ; in others, intromission is more or less interfered with ; 
while in still others the urethra is so misplaced backward that 
fecundation cannot be accomplished. In this division are included 
cases of absence of the penis, hypospadias and epispadias, abnor- 
malities in size, and double penis. 

Ulcerative and other destructive processes in some cases so 
damage and distort the penis that a man may become actually 
impotent as a result. Then, again, the size, structure, and shape 
of the organ may be rendered so abnormal by benign hyperplastic 
processes and by malignant new-growths and preputial calculi that 
coitus cannot be performed. En this morbid category belong cases 
of destructive lesions of the skin of the penis and of the whole 
organ, exuberant vegetations, horny growths, lymphoid connec- 
tive tissue hyperplasia, and cancer of the penis. 

In another class of cases of organic impotence we find degen- 
erative and hyperplastic changes in the corpora cavernosa, and 
morbid conditions of these structures due to curvature and frac- 
ture of the penis. 



CHAPTEE X. 

ORGANIC IMPOTENCE FROM CONGENITAL DEFECTS AND 
MALFORMATIONS OF THE PENIS AND VARICOSITY OF 
ITS DORSAL VEINS. 

A max may be rendered impotent by certain organic and con- 
genital conditions of the penis which impede or wholly prevent 
intromission and fecundation. He is, however, not necessarily 
sterile, since the functional activity of the testes may not be at all 
impaired. He therefore preserves the procreative power (potentia 
generandi), while he lacks the faculty and power of performing 
coitus (potentia coeundi). 

In this form of organic impotence are classified cases of absence 
of the penis, hypospadias and epispadias, abnormalities in the size 
of the organ, and some cases of double penis. Some men having 
two penes, however, are perfectly able to perform coitus, in some 
instances with both organs seriatim. 

ABSENCE OF THE PENIS. 

This anomaly, when congenital, is very rare, while cases of 
rudimetary penis of the infantile type are not especially uncommon. 

GoschlerV case of congenital absence of the penis is very inter- 
esting. The patient was a well and otherwise fully developed man 
of twenty-seven years of age. The scrotum was well formed, and 
the testes and cords were normal (the left testis was at time of 
observation inflamed). No trace of the penis could be discovered, 
but on the anterior wall of the rectum, about four inches above 
the anus in the median line, was a rounded orifice from which 
urine escaped. A sound introduced into the rectum could be 

1 Vierteljahresschrift fur Prakt. Heilkunde. Prague, 1857, vol. lxiii. pp. 89 
et seq. 



ORGANIC IMPOTENCE. 



107 



passed through a urethra one and a half inches long into the 
bladder. In front of the anus was a fold of skin which consisted 
largely of erectile tissue, and which became turgid in sexual ex- 
citement. There was no incontinence of urine in this case. 

RevolatV case was that of a new-born child in whom there 
were no external genitals. There were spina bifida and umbilical 
hernia, below which the urine and meconium escaped through a 
transverse opening. 

Fig. 23. 




Absence of penis due to syphilitic phagedena. 



Nelaton 2 has reported a case of a child, two years old, in which 
there was no penis, though the scrotum and testes were present. 
The urine was passed through the rectum. Cases similar to this 
have also been reported. 

Cases of apparent absence of the penis have been reported. In 
Bouteiller's case the penis could not be seen, though on careful 

1 Journal de Sedillot, vol. xxxii. p. 370. 

2 Demarquay : Maladies Chirurg. du Penis, 1877, p. 539. 



108 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

Fig. 24. 




Absence of penis from gangrene. 
Fig. 25. 




Absence of penis from cancer and cancerous bubo with secondary nodules. 



ORGANIC IMPOTENCE. 



109 



palpation a small, worm-like body was felt beneath the skin, which 
dissection showed was a small penis. Murphey 1 records a some- 
what similar case, in which there was a well-formed scrotum and 
apparently no penis, the urine escaping from the lower part of the 
abdomen. Deep pressure revealed a body which, when dissected 

Fig. 26. 




Double hydrocele with invagination of the penis. 

out, proved to be a small penis, for which the reporter ventured to 
entertain the hope that it would later on be equal to all requirements. 



1 British Medical Journal, 1885, vol. ii. p. 62. 



110 SEXUAL DJSOEDEIiS OF THE MALE AND FEMALE. 

Absence of the penis may result from the phagedena of hard 
and soft chancres (see Fig. 23) and from gangrene (see Fig. 24). 
In cancer of the penis more or less of its continuity is removed 
by amputation. (See Fig. 25.) Strangulation of the penis by 
self-inflicted ligature has been known to produce absence of the 
organ. 

In some cases of enormous hydrocele (see Fig. 26) and of 
scrotal hernia, and in some cases of enormous enlargement of the 

Fig. 27. 




Elephantiasis of the scrotum (and leg) with invagination of the penis. 



testes, the penis is forced backward, and appears to be absent. 
In some of these cases the organ is so enveloped that even in 
erection intromission is rendered impossible. This condition also 
obtains in elephantiasis of the scrotum. (See Fig. 27.) 



ORGANIC IMPOTENCE. 



Ill 



HYPOSPADIAS AND EPISPADIAS, AND TORSION OF 
THE PENIS. 

These rare malformations will not here be described in full, 
but will be considered only in their relation to the sexual act. 

Hypospadias really consists of a greater or less deficiency of 
the corpus spongiosum and of the urethra. When the urethra 
ends at the base of or in the glans the condition is called balanic 




Perineoscrotal hypospadias. (Dolbeau. ) 

hypospadias. In this condition the semen may be discharged into 
the vagina and impregnation may result. 

When the urethra ends in the course of the penis, provided it 
is not too far back, the condition, which is called penile hypos- 
padias, may not prevent fructification of the female ovule, as the 
semen is then discharged into the vagina. When it ends quite 
far back the semen escapes over the external genitals. This also 



112 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

occurs in penoscrotal hypospadias, in which the urethral orifice is 
seated at the angle formed by the penis and scrotum. 

In scrotal and perineo-scrotal hypospadias the semen does not 
come near the genitals of the woman, hence it has no opportunity 
for fructification. Men thus affected are necessarily sterile. (See 
Fig. 28.) 

In epispadias the urethra opens on the upper surface of a mal- 
formed penis, either in its glandular portion, in the continuity of 
the organ, or just at the symphysis pubis. (See Fig. 29.) In 

Fig. 29. 




Epispadias of glans and corpus spongiosum. ( Dolbeau. 



cases of glandular epispadias impregnation of the female may 
occur, and the chances of this event become more remote in pro- 
portion as the opening of the urethra occurs at points further 
back. When the urethra opens at the symphysis pubis the semen 
is thrown outside the vulva, and as a fecundating fluid it is lost. 



PLATE VI, 




Rudimentary Penis with Cryptorehism. 



ORGANIC IMPOTENCE. 1 1 3 

Total absence of the urethra is a very rare malformation. Occlu- 
sion of the canal when it occurs near the glans is remediable by 
operation, and even when seated further back the calibre of the 
canal may be so restored that on intromission fecundation of the 
female ovule may result. 

Torsion of the penis is a very rare condition, complicating 
hypospadias and epispadias. The penis is so twisted on its axis 
that the urethral orifice is abnormally placed. 

ABNORMALITIES IN THE SIZE OF THE PENIS. 

Cases of rudimentary penis have been recorded as well as those 
of the infantile type ; they are, however, of rare occurrence. A 
case of bifid penis, in which the glans and a part of the body of 
the organ were split and the urethral opening was seated back 
and behind the bifurcation, is on record as a classical illustration 
of this rare anomaly. 

Rudimentary penis is of rare occurrence, and is usually coex- 
istent with cryptorchrsm or some other sexual anomaly. 

A striking case of rudimentary penis accompanied with crypt- 
orchism, the testes being in the abdominal cavity, occurred in the 
practice of my friend, Dr. Piffard. In this patient the corpora 
cavernosa and corpus spongiosum were present, and erection was 
possible. The man, however, had little sexual desire. (See Plate 
VI.) 

A case has been recorded by Dummreicher in which a boy of 
twelve had a penis which was only three-fourths of an inch long 
and as thick as a goose-quill. The corpora cavernosa were absent. 

We sometimes meet cases of men of various ages in which the 
penis is no larger than that of a child, and in which, as a rule, the 
testes are very small. In some of these cases a decided increase 
in the size of the organ takes place when coitus is regularly in- 
dulged in. I have seen a number of instances of decidedly under- 
sized penes, Avith long, tight prepuce, which became much larger 
after the parts were circumcised. 

Cases of enlargement of the penis so that it constitutes a mon- 



114 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

strosity are relatively rare. I know of an individual in whom 
the organ when erect was said to be fourteen inches long and pro- 
portionally thick. This man had two wives who died of uterine 
disease, while a third applied for divorce very soon after marriage. 
Many years ago I had under my care a case which, to my mind, 
is unique. The man before his injury had a penis of the ordinary 
size. During the Civil War the man was shot in the base of the 
penis and in the left inguinal region. After the wound healed it 
was noticed that the man's penis began to grow, and this hyper- 

Fig. 30. 




Enormous hypertrophy of whole penis. 

trophy continued for years. When he came under my observation 
his penis was, when flaccid, fully twelve inches long and propor- 
tionally longer when erect. This case was not a simple example 
of traumatic elephantiasis, which is not uncommon, for besides the 
increase in the connective and lymphoid tissues there was commen- 
surate enlargement of the glans penis, the corpora cavernosa, and 
corpus spongiosum. When erect, according to the man's story, 



ORGANIC IMPOTENCE. 11 5 

the penis was of monstrous size, and he was forever barred from 
coitus. (See Fig. 30.) 

In the average run of cases of penis of excessive size the man 
may have connection with some women without injury to them, 
provided care and tact are observed. I had under my care many 
vears ago a man who had been shot in the groin in a drunken 
brawl, and in whom injury to the lymphatics had been produced. 
Following this wound the penis began to swell and grow in 
length until it measured eleven inches in the supple state. In 
this case there was no hypertrophy of the erectile tissues what- 
ever, but enormous hypertrophy of the integument and lym- 
phatic tissues. 

Elephantiasis of the penis leads to large deformities. In 
phimosis, particularly when intrapreputial chancres and chan- 
croids are present, the penis often becomes of large size. When 
the hard oedema of syphilis attacks this organ it becomes greatly 
enlarged in all directions. 

DOUBLE PENIS. 

This anomaly is very rare, and is usually found in cases of that 
monstrosity called foetal inclusion. 

In Fig. 31 are portrayed the genital organs of a man 1 who was 
exhibited in all the large clinics of France and Spain. 

It will be seen that between the two legs a third hangs down, 
the insertion of which is seated between the scrotum and anus. 
This supernumerary limb is atrophied and its joints are ankylosed. 
There are two well-developed penes, and to each one a scrotum 
containing a normal testis is furnished, the two sacs being joined 
in the median line. These penes became erect at the same time, 
and either one could be used in coitus. Ejaculation or micturi- 
tion occurred from each organ synchronously. 

A case has been reported in which there was no foetal inclusion. 
It was that of a healthy man of forty-two, who had two distinct 

1 Kevue Photographique des Hopitaux, 1869, vol. i. p. 103. 



11(5 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

Fig. 31. 




Double penis. 



ORGANIC IMPOTENCE. 117 

penes of normal size, each attached by its root to the pubic sym- 
physis. Each penis was well developed, and the two were enclosed 
as far as the base of the glans in a common integumentary sheath. 
The right meatus was normal, the urine escaping from it and also 
from a point behind in the perineum. On elevating the penes the 
orinGe of a large, healthy canal was seen just where the root of the 
scrotum should have been attached. On the right side of this 
orifice was a prominence which contained a rather under-sized 
testis, while the left organ lay over the tendon of origin of the 
adductor longus in the left groin. Both penes became erect at 
the same time. In this case the left lower limb was shorter than 
the right, a deformity which was congenital. 

ENLARGEMENT OF THE DORSAL VEINS OF THE 

PENIS. 

It has been claimed by several authors that in some cases there 
is abnormal enlargement of the dorsal veins of the penis, and that 
erection and intromission are impaired and even aborted by the 
blood in these varicose canals being emptied too promptly and 
much more rapidly than the arteries can fill them. 

In order to remedy this mechanical form of impotence it has been 
proposed to ligate the dorsal veins of the penis, and the results 
are said to be excellent in the hands of some authors. In one 
case reported the effect of this operation is little less than miracu- 
lous ! The author had faithfully used the various aphrodisiac 
remedies, which had utterly failed in a rather obstinate case, so 
he then resorted to operation upon the dorsal veins of the penis. 
He says : 

" I therefore determined to ligate a couple of the larger sub- 
cutaneous veins at the base of the penis and watch the effect. 
This was very easily done by the use of cocaine. A vein on each 
side of the penis was exposed, ligated in two places and severed 
between the ligatures. A dressing was lightly applied and held 
in position by a strip of adhesive plaster placed longitudinally. 
The result was immediate. In less than five minutes after leaving 



118 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

my office he had an erection. That night he was awakened by a 
powerful erection, which made the bandage so painfully tight that 
he was obliged to jump out of bed onto the cold floor to subdue 
it. Primary union was prevented by the frequent erections, but 
the success of the operation was certain. 

"Two months later he reported himself well, mentally and 
physically ; his sexual appetite had returned, and since the opera- 
tion his power of maintaining erections had been as good as ever." 

It is well to lay emphasis on the fact that this procedure has 
not been thoroughly tested, and that it has not as yet received 
authoritative indorsement. 



CHAPTER XI. 

OEGANIC IMPOTENCE FEOM DESTRUCTION OF THE INTEGU- 
MENT OF THE PENIS, AND FEOM BENIGN AND MALIG- 
NANT NEW-GEOWTHS AND PEEPUTIAL CALCULI. 

DESTRUCTIVE LESIONS OF THE INTEGUMENT OF 
THE PENIS. 

The integument of the penis may, in consequence of disease 
or traumatism, be so much destroyed that when cicatrization is 
complete intromission of the organ may be either much impaired 
or wholly prevented. 

Chancroidal Ulceration. 

Chancroidal ulceration may be so severe and extensive that 
much of the tegumentary sheath of the penis is destroyed. In 
Fig. 32 is portrayed a penis which had been the seat of several 
large chancroids. After healing, the organ was so curved down- 
ward and twisted at its end that coitus was practically impossible. 
I have seen many instances of this kind, some of which were more 
pronounced than the one here mentioned. 

Phagedena in Syphilis. 

Phagedena may attack the initial lesion when seated on the 
penis, and so destroy or distort that organ that coitus is rendered 
impossible. In general, the destructive action occurs in the glans 
penis or in the prepuce, and the process is arrested before serious 
damage is produced. It sometimes happens, particularly in cases 
of phimosis, that a subpreputial initial lesion becomes attacked 
by phagedena, and, owing to want of care, or poor care, more or 
less of the organ is destroyed. In these days of strict antisepsis 



120 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

phagedena is not a common complication of primary syphilitic 
lesions, and in the event of its occurrence it is much more promptly 
checked than it was twenty years ago. 

Fig. 32. 




Cicatrization of integument of the penis following chancroids. 

Phagedena has been known to attack the urethra and to run 
down the canal for short or long distances, even to the peno-scrotal 
angle. In these rare cases, of which I have seen several, organic 



ORGANIC IMPOTENCE. 



121 



impotence was produced. I have several times been able to avert 
this process before it had extended much beyond the meatus. In 
these latter cases a dense fibrous stricture is usually produced. 



Gangrene of the Penis. 

It usually happens that gangrene primarily attacks and destroys 
some part of the integument of the penis and also the glans, 



Fig. 2>{ 




\m* 







Gangrene of the integument ot the penis. 

with perhaps some of the tissue beyond. The result of gangrene 
of the penis is well shown in Fig. 33, in which the greater por- 
tion of the skin of the organ, beginning near the preputial orifice 
and extending almost to the abdomen, Avas destroyed. When full 
healing had taken place in this case the penis was so pushed back- 
ward to the abdomen by the sclerosing cicatrization that erections 



122 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

were abortive and penetration was rendered impossible. I have 
seen other instances in which gangrene of the penis w T as followed 
by such deformity that coitus became difficult or incomplete. 

Traumatism. 

Injury to the integument of the penis, beyond mere bruises, is 
not very common. Laceration of these parts is of very infrequent 
occurrence. 

Fig. 34. 




Showing destruction of the integument of the penis resulting from traumatism. 

In Fig. 34 is shown an example of a lacerated wound of the 
penis of much extent and severity. As a result of his being 
struck by a revolving wheel, the penis of this patient was nearly 



ORGANIC IMPOTENCE. 123 

denuded of its integument in its whole circumference. In cases 
like this the resulting cicatrix is so dense and firm that the organ 
becomes somewhat twisted, and on erection it is so distorted that 
intromission is either very difficult, painful, or impossible. 

In these cases the affected surfaces are so studded with micro- 
organisms that skin-grafts will fail to take root. Then, again, the 
mobile condition of the penis is such that a perfect result is ren- 
dered impossible. 

VEGETATIONS OF THE PENIS. 

Vegetations are papillary new-growths, due to hyperplasia of 
the connective tissue and of the epidermis. They are developed 
on the mucous membrane of the penis and at its junction with the 
skin, in consequence of the irritation produced by decomposing 
secretions and by pus. The hyperemia left by chancres and chan- 
croids on the glans or prepuce may lead to the development of 
vegetations. 

These lesions begin as little red spots, which soon become salient, 
and from a papular condition they grow rapidly and exuberantly 
until papillomatous or cauliflower-like growths are produced. 
They may be rounded and sessile, or pedunculated, or Indian- 
club-shaped. They form masses like strawberries, and large 
aggregations of them very much resemble cauliflower growths. 
In color they may be very red, or of a pink or even grayish tint. 

The sites more frequently attacked by vegetations are the cor- 
onal sulcus, the inner surface of the prepuce, the region of the 
frsenum, and the lips of the meatus. 

When small these lesions may not cause impediment to coitus ; 
but when they become large, and constitute fungating masses 
and cauliflower excrescences, they render intromission impossible. 

In cases of long and tight prepuce they often lead to phimosis, 
which may end in perforation of that appendage and to gangrene 
and hemorrhage. 

In Fig. 35, vegetations of the coronal sulcus, the whole of the 
mucous layer of the prepuce, and of the meatus are clearly shown. 



124 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

In this case coitus was impossible and urination was much hin- 
dered. 

I have several times seen cases in which men were unfitted and 
incapable of fructifying coitus with their wives by reason of nearly 

Fig. 35. 




Vegetations of the glans and prepuce. 

complete stenosis of the preputial orifice by reason of its natural 
smallness and of the blocking up of the penis by vegetations. 
This condition is well shown in Fig. 36. In this case after circum- 
cision the man's wife promptly became pregnant. 

The diagnosis of warts is usually very readily made. In some 



ORGANIC IMPOTENCE. 



125 



cases of condylomata lata papillomatous exuberance may occur, 
and the lesions may look like simple vegetations. Since condylo- 
mata lata are usually found about and around the anus and the 
inner surface of the thighs and on the scrotum, it is well when 
large, flat warts are found on these sites to inquire into the history 
of the case in order to determine whether syphilis may be present 
as a morbid factor. 

Fig. 36. 




Vegetations of tlie preputial orifice, causing almost complete stenosis. 

The prognosis of warts of the penis is usually good, provided 
intelligent treatment is instituted. In old subjects, both male 
and female, the occurrence of warts about the genitals should 
always suggest to the mind of the surgeon the predisposition of 
these lesions to malignant degeneration, and their removal should 
be promptly accomplished. 

Treatment. The treatment of warts of the penis when they 
are small is very simple. The penis should be thoroughly cleansed 



126 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

and anesthetized with cocaine and the lesions removed with the 
curette or small curved scissors. Absolute cleanliness and dryness 
of the penis are necessary to prevent a relapse. Destructive cau- 
terization by the acid nitrate of mercury, tincture of iodine, solu- 
tions of chloride or subsulphate of iron, chloro-acetic or lactic 

Fig. 37. 




Horns of the penis. (After Pick. ) 

acid may be employed when the warts are very small and sharply 
localized, particularly when patients are very nervous and fidgety 
as to operations. 

Whenever possible the curette should be used ; but when the 
Lesions are large, hard, and densely hypertrophied it may be 



ORGANIC IMPOTENCE. 127 

unfavorable to remove them with the curette, and in this event 
the galvano-cautery acts very efficiently, and if carefully and 
slowly operated no hemorrhage follows. 

When the meatus is the seat of warts care should be taken that 
the lips be not damaged, since stenosis may follow^. After removal 
it is nece^iry to use dry powders, such as zinc oxide, nosophen, 
an( erin .ol, and to keep the parts covered with absorbent gauze. 

HORNY GROWTHS OF THE PENIS. 

This form of new-growths on the penis is very rare, but its 
existence always proves a bar to coitus. 

Horns of the penis take their origin on the corona in the coronal 
sulcus and on the inner aspect of the prepuce, particularly near 
the frammn. These horns are usually developed from warts in 
persons in whom there has been some chronic irritative process on 
the prepuce or glans. 

In Figs. 37 and 38 are portrayed the features of the remark- 
ably striking case of Pick. 1 The large horn sprang from the pre- 
nuce and glans, its base being embedded like a nail in its matrix 
uxi the right side down toward the frsenum. From its base the 
\ rn jutted downward and upward to the left and in front of the 
meatus. From the base of the glans several small horns sprang 
aud showed a tendency to come upward in front of the glans. 
AVhen the penis was placed in line with the abdomen the large 
horn presented an appearance not unlike the crest of a dragoon's 
helmet. The horn was two and a half inches long. In other 
reported cases these excrescences have been noted as being one- 
ha f to one and three-quarter inches in length. Their breadth 
is usually less than an inch, and they are generally somewhat 

perecl in shape toward their ends, which are usually truncated. 
In color" they are brown, greenish-brown, and black, and in struc- 
ture hard, firm, and brittle. 

Treatment. These growths should be thoroughly removed, 
and more or less of the glans should be ablated if necessary. 

1 Yierteljahr. fur Derm, mid Syphilis, 1875, Band. ii. pp. 315 et seq. 



128 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

They sometimes return after removal, and they are rather infre- 
quently the precursors of malignant degeneration. 

Fig. 38. 




Horns of the penis. (After Pick. 



ELEPHANTIASIS OF THE PENIS. 

In some cases elephantiasis of the penis exists independently 
of the scrotum, in others the two parts are attacked. The scrotum 
alone is involved in some rare cases. In such cases there is an 
impediment to the sexual act, and in many its accomplishment is 
utterly impossible. 

The penis becomes much enlarged, so that it may reach to the 
knees, and its diameter is many times increased. The skin becomes 



ORGANIC IMPOTENCE. 



129 



more dense and thicker than normal, has a firm, brawny feel, and 
is channelled by numerous furrows, which run in various direc- 



Fig. 39. 





Elephantiasis of the penis. 

tions. The prepuce becomes involved early, and the glans recedes 
behind its opening and cannot be pushed through it. (See Fig. 39.) 



130 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

Elephantiasis of the scrotum consists of a lymphoid and fibrous 
infiltration into the entire thickness of the tissue. The sac be- 
comes large and heavy and drags down the abdominal skin, and 
as the morbid process goes on the penis disappears and is slowly 
engulfed in the scrotal mass. In this event the prepuce forms 
a fictitious urethra, which ends in a depression in the median line of 
the scrotum, in which is formed a gutter for the passage of the urine. 

Elephantiasis of the genitals occurs in tropical countries in an 
endemic form, and very rarely in colder countries in sporadic 
form, usually as a result of some traumatism or irritation. 

Treatment. The treatment of this deformity, which renders 
sexual intercourse impossible, is the ablation of the redundant 
parts according to the topography, with the purpose of producing 
as symmetrical a penis and scrotum as possible. 

CANCER OF THE PENIS. 

Cancer of the penis, as a rule, is an affection peculiar to advanced 
life, but less frequently is found in men between the ages of twenty 
and fifty. Between the fortieth and fiftieth years it is far from 
uncommon. 

Cancer of the penis usually begins in an insignificant manner, 
as a little wart, a thickened patch of epithelium, and as a small 
chronic ulcer or fissure. As a rule, the primary lesion is so devoid 
of symptoms that it causes no mental or physical uneasiness, and 
its development is usually very slow. 

It begins either in the coronal sulcus or on the corona near the 
frcenum, on the inner surface of the prepuce, and very exception- 
ally in the uretkua. When the prepuce is long there maybe mild 
pruritus or a sensation of heat, due to the irritation of the secre- 
tions of the parts. Usually after a chronic period of quiescence 
luxuriant growth occurs and the penis becomes much enlarged 
and distorted toward its end by fleshy masses and exuberant cauli- 
flower-like tumors. As a result, deformities and distortions of 
varying appearance are produced (see Figs. 40 and 41), coitus 
becomes impossible and urination is much impeded. 



ORGANIC IMPOTENCE. 



131 



When epithelioma of the penis becomes fully developed, lanci- 
nating and persistent pains are complained of and hemorrhage, 
more or less severe, may occur. As time goes on the general 
health is undermined and the patient dies of marasmus, or, very 



Fig. 40. 




Showing epitheliomatous degeneration of glans penis bursting through the 
prepuce, which was phimotic. 



rarely, of metastasis into some of the viscera. As the lesion of 
the penis progresses implication of the inguinal ganglia occurs, 
and palpation shows these organs to be large, hard, painless, and 
indolent. 



132 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

The diagnosis of cancer of the penis when fully developed is 
usually very easy. Any chronic nodule or ulcer with hard and 
perhaps exuberantly developed base or surroundings, particularly 
in men over forty years of age, should be regarded with much 
suspicion, carefully watched, and treated early. It is necessary 
to remember that in younger men the initial lesion may be very 
exuberant, dense in structure, and perhaps more or less fungating 
on its surface, and that it may be mistaken for cancer. 

Fig. 41. 




Showing the under surface of case shown in Fig. 40, with new-growth 
and stenosed preputial orifice. 

The prognosis of cancer of the penis depends entirely on the 
fact of its early recognition and thorough removal, together with 
all the ganglia in the groins and perhaps in the thighs. 

The treatment of cancer of the penis, according to the extent 
and severity of the lesion, consists in either amputation or extirpa- 
tion, with the removal of the lymphatic ganglia. (For a full ac- 
count of this affection, see my work A Practical Treatise on Genito- 
urinary and Venereal Diseases and Syphilis. Philadelphia, 1900.) 



ORGANIC IMPOTENCE. 



133 



INDURATING (EDEMA OF THE PENIS. 

Indurating oedema of the penis is a somewhat exceptional com- 
plication of hard chancre of this organ, and owing to its chronicity 
and its hyperplastic tendency, it may in some cases lead to per- 
manent deformity and to organic impotence. 

Indurating oedema begins in a slow, paiuless manner around the 
margin of the initial lesion or lesions of syphilis. It is noticed 

Fig. 42. 




Indurating oedema of the penis with hard chancre on the outer layer 
of the prepuce. Great enlargement of the organ. 

that the tissues begin to swell and present a dull-red or purplish 
hue, and a density of structure a little less compact than that 
of a typical hard chancre. Usually the hard chancre is seated on 
the prepuce or the prepuce and glans, and from these foci the 
hyperplastic process may gradually creep upward, and in severe 
cases involve the whole penis (see Fig. 42), and exceptionally it 



134 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

may involve the penis and the scrotum. (See Fig. 44.) In rather 
rare cases when the hard chancre begins on the cutaneous envelope 
of the penis, this indurating complication may occur in these parts, 
and then it usually first travels downward to the preputial region 
and shortly afterward upward toward the pubis. (See Fig. 43.) 

Fig. 43. 




Hard chancre with very extensive oedema of the penis. Great enlargement 

of the organ. 

In most cases want of proper and prompt treatment of the hard 
chancre, injurious and intemperate cauterization, and uncleanliness 
are the causes of irritation of the initial syphilitic lesion. It is gen- 
erally observed that when active measures are promptly adopted 
for the cure of the indurating process before much tissue has been 
invaded, resolution may quite speedily set in ; but that when the 



ORGANIC IMPOTENCE. 



135 



treatment has been delayed (particularly if the parts are irritated) 
and the lesion is well under way, its tendency to further extend is 
very^great, and its resolution is long delayed. 

Fig. 44. 




Indurating oedema of the penis and scrotum from hard chancre of the inner 
layer of the prepuce. 

It is this sluggish chronicity of the lesion of the penis which 
leads to the great hypertrophy of the organ and its frequent and 
more or less permanent distortion. 

Under vigorous treatment resolution may occur in even severe 
cases in several or many months, and during this period coitus is 
usually impracticable. In some cases such an elephantine hyper- 
trophy of the penis is produced that the patient is rendered 
organically impotent. 

Treatment. In these cases active internal and local treatment 
is imperatively demanded. After careful antiseptic cleansing the 
organ must be kept enveloped in strong mercurial ointment, freely 
spread on lint, which is to be held in place by gutta-percha tissue. 



136 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

Internally an energetic and efficient inunction course should be 
adopted, and in the event of prompt resolution not being observed, 
resort should be had to the ingestion of the mixed treatment in 
full dose. 

PREPUTIAL CALCULI. 

A peculiar form of distortion of the penis which, when well 
marked, produces organic impotence is caused by the presence 
of calculi in the preputial sac. There may be one, two, or three 
calculi present, and the distortion of the organ varies according 
to their number and size. As a rule, intromission of the penis 
becomes impossible and coitus so painful that it is usually not 
indulged in by these sufferers. 

Fig. 45. 




Preputial calculi. ( Natural size. ) 

Preputial calculi may be seated side by side, and may then be 
symmetrically faceted to each other, or one stone may be seated 
on the top of the other in a concavity in which the convex base 
of its upper fellow is smoothly placed. It is said that preputial 
calculi are not very uncommon in China, particularly in the per- 
sons of the natives. In Fig. 45 are well shown two preputial 
calculi, which were removed from a Chinaman in Canton, China, 
by my friend, Dr. J. A. Andrews. 

I have seen two instances in which such a large quantity of 
dried smegma was present in cases of phimotic prepuce that 
intromission was difficult or impossible. 



CHAPTER XII. 

ORGANIC IMPOTENCE DUE TO DEGENERATIVE, HYPER- 
PLASTIC AND TRAUMATIC CHANGES IN THE CORPORA 
CAVERNOSA. 

In this category are included ossification of the penis, fibroid 
sclerosis, syphilitic nodes, together with curvature and fracture of 
the organ. 

OSSIFICATION OF THE PENIS. 

This affection is very rare, and is denominated calcification by 
some authors. It occurs in middle-aged and old men ; hence, as 
a rule, it does not cause much mental disturbance, though it may 
interfere with and even entirely prevent coitus. The parts in- 
volved are the sheaths of the corpora cavernosa and the septum 
pectinif orme. The bony growth may be in plates, as it is usually 
found in the superfices of the corpora cavernosa, or in rod-shape 
when the septum pectinif orme is attacked. 

Ossification of the penis, which is always partial, takes place 
very insidiously and without pain, and the patient first becomes 
aware of its existence by the impediment it offers to coitus or the 
curvature which it causes to the organ. In a case reported by 
MacClennan, 1 in which there was so much distortion of the penis 
that urination was accomplished with the greatest difficulty, the 
whole length of the septum was ossified, and coitus was rendered 
impossible. This bony mass was dissected out and a fairly good 
result was obtained in remedying the curvature and restoring the 
function of the organ. In Fig. 46 is well shown an example of 
longitudinal bony growth in the median line of the penis, which 

1 Phila. Monthly Journal of Medicine and Surgery, 1827, p. 256. 



138 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

was observed by Demarquay 1 in the Pathological Museum of 
Vienna. No facts concerning the case were obtained. 

The curvature produced by ossification of the penis may be 
either upward or downward. In this affection erections are 

Fig. 46. 




Bony growths ot the penis, shown as white bands in the middle of dorsum. 
(After Demakquay. ) 

painful, manipulation of the penis causes suffering, and in its 
quiescent state the organ is more than normally sensitive. 

According to Demarquay, there is a case on record in which an 
oxdriver had a penis which was wholly ossified, always in erec- 
tion, and the cause of great suffering to his wife. The same 

1 Op. cit, p. 353. 



ORGANIC IMPOTENCE. 139 

author mentions a case observed by Velpeau, in which a bony 
growth sprang from the pubic bone and invaded the left side of 
the penis for a distance of fifteen lines. 

Treatment. Nothing but removal by means of the knife is 
indicated in these cases, and it is probable that the cicatrix result- 
ing from the wound may lead to bad distortion of the penis. The 
affection is practically incurable. 

In some of these cases, when the plates are superficial and the 
bony median cords accessible to the knife, removal may be effected 
by operation, and improvement of the patient's condition may 
result. Internal or external medication is worse than useless. 

FIBROID SCLEROSIS OF THE CORPORA CAVERNOSA. 

This affection has heretofore been described under the title of 
chronic circumscribed inflammation of the corpora cavernosa, an 
obvious misnomer, since no one has ever observed any inflamma- 
tory condition connected with it. 

This affection begins slowly, painlessly, and insidiously, and, as 
a rule, is first recognized by the patient as a little bean-like lump 
or plate of tissue in the theca of the corpora cavernosa, which 
may be slightly painful on pressure or during erection. 

In exceptional cases I have noted that the patient complained 
of pain in the penis, particularly on erection, when on careful pal- 
pation no change in the corpora cavernosa could be made out, even 
after several examinations. In these cases the only evidences of 
lesion were the tendency of the penis to curve upward and the 
presence of pain when an attempt was made to straighten the 
curved organ. In these cases the fibroid proliferation was well 
under way, but it had not become sufficiently compact to cause 
such a change in the tissues as to be perceptible to the fingers. 

As a rule, the sclerosis is tolerably well advanced when the 
surgeon is consulted, and he finds a hard, firm plate of tissue a 
line or two in thickness, perhaps the size of one's thumb-nail or 
larger, seated in the superficial portion of the corpora cavernosa, 
about equally on each side of the median line, like a saddle. Its 



140 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

margins are usually sharply defined and regular, or they may ex- 
ceptionally be uneven, slightly nodulated, and perhaps thickened. 
The deeper parts are, as a rule, free from the disease, but excep- 
tionally we find that the morbid process has extended downward 
into the trabecular The induration of the plate is variable ; in 
the early stages it is usually not very dense, but in older cases it 
may be of cartilaginous hardness. Usually these plates have a 
kind of elasticity which gives to the finger a sensation quite dif- 
ferent from that offered by the bony and cartilaginous plates 
sometimes found here. As, however, these plates grow old, they 
may become very dense and wholly inelastic. 

The lesion may occupy one corpus cavernosum, or both ; but 
it almost always seems to begin on the dorsum of the penis, par- 
ticularly near the median line. I have recently seen four cases in 
which the plates began on the sides of the penis near the line of 
apposition of the corpora cavernosa with the corpus spongiosum. 
In two cases symmetrical plates over an inch long were found, 
one on each side of the penis. In a third case there was a large, 
firm plate on one side, and a smaller and more elastic one on the 
other side of the penis. In the fourth case there was but one 
small plate on the left side of the penis. In all these cases the 
curvature of the penis was well marked and downward in direc- 
tion. 

In general, these plates are found to be the shape of a saddle, 
usually symmetrically placed over the cavernous bodies and well 
welded together in the median line. While this arrangement is 
the one most commonly found, I have seen two exceptional cases, 
in which there seemed to be a little sulcus directly in the middle 
line of the penis, where the two plates met but did not join to- 
gether. This depressed line seemed to be composed of unaffected 
tissue, and it acted as a hinge upon which either of the two plates 
could be slightly moved or tilted upward or downward. 

The smaller plates are ovoid, and they have been found as long 
as two and even three inches and as small as half an inch. As a 
rule, the sclerosis attacks the corpora cavernosa, but quite excep- 
tionally it involves the corpus spongiosum. This is shown in 



ORGANIC IMPOTENCE. 



141 



Fig. 47, which is a schematic representation of a case once under 
my care, in which on each side of the penis there was an offshoot 
extending around to the frsenum along the course of the lym- 
phatics. 

In some rare cases in which the lesion is unilaterally developed 
its inner edge usually impinges on the median dorsal line of the 
penis. 

As a rule, we find but one saddle-like plate, but in some in- 
stances I have seen two, one just behind the glans penis, and the 
other further up the organ, near its root. Another anomalous 
form of this affection consists in the usual saddle-like lesion with 



Fig. 47. 




Fibroid sclerosis of the corpora cavernosa. 

one or two small plaques seated on one or both sides of the cor- 
pora cavernosa. 

These plates may grow in all the directions of their margin, but 
usually to a greater extent in an antero-posterior direction. They 
not infrequently remain stationary for a long period, but usually 
extend quite slowly and insidiously. 

In the majority of cases the lesion runs its course in the flat, 
superficial manner just described ; but in some instances the scle- 
rosing process extends deeper into the trabeculated tissue of the 
corpora cavernosa and produces nodular masses of varying size. 

This affection interferes more or less with erection, according to 



142 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

the size of the plaque. If this is small it may cause but slight 
distortion of the penis ; but as it grows larger it so interferes with 
the proper erection of the organ that it is bent exceptionally almost 
to a right angle, but usually upward and toward the affected side, 
or it may be somewhat twisted. In most cases the erectile tissue 
underlying the lesion in the whole length of the organ becomes 
hard and firm during erection. When, however, the trabeculated 
tissues have been attacked by these sclerotic infiltrations, the penis 
beyond them is not at all congested, while the erection in the 
proximal part is complete. In this event the organ may resemble 
a flail, the firm part near the body being the handle, and the distal 
part or swingle hanging flaccid, perhaps nearly at a right angle. 

In general, patients having plates in the dorsum of the penis 
complain that when erect the end of the organ stands so near the 
abdominal wall that intromission is rendered impossible, and any 
attempt at straightening it out is attended with severe pain. This 
feature is shown in the schematic drawing made by a patient of 
his own penis when erect. (See Fig. 48.) In this case a very 
curious and exceptional condition existed — namely, the organ be- 
came distended and erect in its distal and unaffected four-fifths, 
whereas at its proximal sclerotic portion near the body it became 
much less distended and was somewhat limber. In this condi- 
tion intromission was only possible (and then with much difficulty) 
when the vagina was very large and moist. 

The appearances presented by another exceptional case are 
shown in Fig. 49, which is taken from a drawing furnished by 
the patient of his penis in a state of erection. The distal third 
of the corpora cavernosa behind the glans was the seat of two 
long plates, which greatly reduced the size of the penis and gave 
it a decided upward curvature. The unaffected part behind be- 
came normally enlarged, but engorgement never took place in the 
glans penis. In his description of his case this patient said that 
his penis when rigid resembled a plucked turkey, the head being 
the glans, the affected portion the neck, and the body being the 
proximal part of the penis, which swelled out during erection. 
In this case intercourse was painful and unsatisfactory. In some 



ORGANIC IMPOTENCE. 



143 



cases the glans and the penis itself may feel cold, and the glans 
may be so anaesthetic that there is no vigor in coitus, and as a 



Fig. 48. 




/// 
V 



Fibroid sclerosis of the corpora cavernosa. 



result such a patient may be aspermatous by reason of the non- 
occurrence of ejaculation. 



144 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

This affection is peculiar to those of middle and advanced age. 
I have seen it once at thirty, in another case at thirty-five, and in 
several cases at the fortieth year. As a rule, these patients pre- 
sent themselves when about fifty years old, and from that time 
on to sixty or seventy years. 

Etiology. We have no precise knowledge as to the cause of 
this affection. By some it is thought to be the result of a gouty 
condition, and by others that it is caused by diabetes. Notwith- 
standing that Verneuil and Tuffier 1 in twenty-six cases found 

Fig. 49. 




Fibroid sclerosis of the corpora cavernosa. 

fifteen patients to be gouty and eleven to be diabetic, it does not 
follow that these conditions were true etiological factors. I have 
seen so many cases of this affection in absolutely healthy men, 
who were not gouty and whose urine did not contain sugar, that I 
am very skeptical as to the influence of a diathesis in producing that 
peculiar sclerosing process. In all probability the origin is local. 
The euphemistic diagnosis of gout in the penis is very gratify- 
ing to some old men. 



1 Annales des Mai. des Org. Gen.-urin., 1885, pp. 401 et seq. 



ORGANIC IMPOTENCE. 145 

Close interrogation of intelligent patients thus affected usually 
brings out no facts as to its origin. In some exceptional cases 
there is a vague recollection of traumatism, but, as a rule, nothing 
can be learned from the patient as to the cause of his trouble. 

Pathology. According to Turner and Leloir, these nodules 
resemble microscopically keloid, there being a fibrous network of 
tissue like that of scars, with few vessels and islets of embryonic 
cells, showing a tendency to fibrous transformation. In short, 
the process is a chronic fibroid sclerosis. The statement that this 
affection is caused by thrombosis of the venous spaces is not sup- 
ported by any scientific evidence. 

Two cases have been reported in which, after the exsection of 
plate-like masses from the penis macroscopically similar to fibroid 
sclerosis, the microscopical diagnosis was said to be that of a malig- 
nant new-growth called endothelioma. As these cases were not 
critically studied and the full facts concerning them have not 
been published, it would be unwise at this time to claim that 
fibroid sclerosis is of a malignant nature. I have observed very 
many such cases over a long stretch of years, and I have never 
seen in them at any time whatever any evidence of malignant 
degeneration. It is important that this point should be clearly 
remembered in order that unnecessary operations and mutilations 
shall not be performed on one suffering from fibroid sclerosis of 
the corpora cavernosa. 

Prognosis. The prognosis of this affection is very unsatisfac- 
tory. There is no case on record in which this sclerosis has dis- 
appeared. It has been stated that in some cases the affection 
crept backward, and then interfered less with erections than it 
did when it was more distally placed. In the very many cases 
I have seen and studied no such auspicious turn of affairs took 
place. As this trouble is peculiar to men who are growing old, 
and who are in general no longer eager for sexual activity, it is 
in most cases complacently borne, and the patients do the best 
the}' can in their crippled condition. 

Treatment. Little can be done for this affection. Most patients 
desire at least to make an effort to remove their disability. In 

10 



146 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

this spirit mild blisters, mercurial inunctions, applications of iodine, 
iehthyol ointment, and the use of the constant current may be tried, 
and for a time iodide of potassium may be given internally. Such, 
however, is the uncertainty of ultimate favorable results that one 
is not warranted in causing these patients inconvenience or suffer- 



SYPHILITIC NODES IN THE CORPORA CAVERNOSA 
AND CORPUS SPONGIOSUM. 

In the tertiary, and very exceptionally in the secondary, period 
of syphilis the erectile tissues of the penis may be attacked by 
localized gummatous infiltrations. The parts attacked are the 
corpora cavernosa and the corpus spongiosum. The involvement 
of these structures by syphilis is very rare, and one part is attacked 
about as frequently as the others. 

When the corpora cavernosa are attacked usually one of the 
bodies is the seat of the lesion, and very exceptionally two are 
involved. As a rule, the patient experiences no pain, and he finds 
by accident a nodule of the size of a pea or a nutmeg, or even of 
larger dimensions, in the meshes of the erectile tissue. These 
nodules are sharply denned, of roundish shape, of firm consist- 
ence, and they may even reveal a quite dense hardness. Usually, 
in this, as we may term it, syphilitic cavernitis the theca of the 
parts is not involved, and the nodule can be felt as a deep-seated 
tumor. Exceptionally, I have seen such a nodule adherent to a 
goodly sized plaque in the theca, and still more exceptionally I 
have seen a flat, gummatous infiltration into the theca, with pro- 
gressive involvement of the areolae of the cavernous tissue. 

Pea-sized or nutmeg-sized nodules of the corpus spongiosum, 
in most cases involving the whole of the circumference, and ex- 
ceptionally limited to the upper or lower wall, are also somewhat 
rarely seen. These lesions are quite firm, but not cartilaginous 
in consistence, and their outline can usually be quite sharply de- 
fined by the fingers. 

All these lesions run an indolent course, and, as a rule, do not 
soften and form abscesses. They cause trouble and disquietude 



ORGANIC IMPOTENCE. 147 

to patients by reason of the curvature of the penis which they 
produce, which may be upward or downward or to the sides. 
Thus interference with coitus may be produced, and in many in- 
stances intromission may be rendered impossible. 

These lesions of the corpora cavernosa run an indolent course, 
with little tendency to involution. In some cases they soften and 
are gradually absorbed, and then distinct loss of tissue is left. 
In other cases the breaking-down of the tumor leads to an abscess 
which may be slow in healing. In either of these events loss of 
tissue and curvature of the penis result. If the case is seen early 
and vigorous treatment is instituted, these nodules promptly show 
signs of resolution, and they may disappear without perceptible 
damage to the part. In some cases a slight fibroid thickening 
may be felt. 

Syphilitic nodules of the corpus spongiosum run a similar course 
to those of the cavernous bodies. In the event of spontaneous 
resolution, of softening, or of abscess formation, there is danger 
of the formation of a dense fibroid stricture of the urethra. If, 
however, the case is seen early, the treatment may promptly cause 
the absorption of the infiltration, and little, if any, damage to the 
urethra and spongy body may be left. In some cases slight thick- 
ening of the urethral wall is produced. 

Diagnosis. In general, the deep-seated nodular form of 
syphilitic infiltration in the corpora cavernosa is so well marked 
that no mistake in diagnosis will occur. When there is a plaque- 
like infiltration of the theca of the cavernous bodies the exist- 
ence of fibroid sclerosis may be suspected. In all cases of doubt 
we must depend on the history and on the results of anti syphilitic 
treatment, which is usually promptly curative in the specific 
affection and powerless in that of simple origin. The nodules 
of the corpus spongiosum, as a rule, readily disappear under 
treatment. 

Prognosis. When these syphilitic nodules are seen early and 
are vigorously treated they will promptly undergo resolution, and 
perhaps leave little damage. In old, neglected cases the integrity 
of the tissues is more or less impaired. 



148 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

Treatment. An active mixed treatment should be adminis- 
tered internally, and mercurial ointment or plaster should be kept 
over the site of the lesion. 

CURVATURE OF THE PENIS. 

This condition is sometimes found in patients whose organ has 
not been injured. In some cases the curvature is slight and 
upward ; in others, moderately downward, while in some there 
is a decided twist of the organ, usually to the left. In none of 
these cases is there any material interference with coitus. I have 
seen decided lateral twists in the penis in confirmed masturbators, 
which were probably due to the abuse to which the organ had 
been subjected. 

Various abnormalities of the penis may be accompanied by 
curvature of the organ. The most common cause of slight 
curvature is shortness of the frsenum, which, as a rule, is readily 
relieved by operation. 

In some rare cases the septum of the corpora cavernosa forms 
a distinct string or cord just above the corpus spongiosum, and it 
draws down the penis toward the scrotum. This condition also 
may be relieved by operation. 

Hypospadias, with adhesion to the scrotum, is a rare condition, 
and is usually complicated with curvature of the penis, due in 
some cases to the cord-like condition of the septum of the corpora 
cavernosa. This condition may be much improved or relieved by 
plastic operation. 

Congenital adhesion of the penis without hypospadias is some- 
times found. In this state the penis is either wholly enveloped 
by the scrotal tissue or it is attached by its inferior surface to the 
bag by means of a webbed band of integument. The glans is 
usually free, and from the meatus the urine dribbles downward. 
The penis being thus bound down, when it becomes erect it is 
curved downward, and intromission is impossible. (See Fig. 50.) 

Curvature of the penis from shortness of the corpus spongiosum 
is (mite rare. A dense and inelastic condition of the spongy body, 



ORGANIC IMPOTENCE. 



149 



either congenital or the result of gonorrhoea! inflammation, in some 
rare cases leads to downward curvature, which cannot be thoroughly 
relieved by operation. 

Injury to the corpora cavernosa from abscess, gummatous infil- 
tration, partial or complete fracture, and thrombosis may result in 
curvature of the penis. In fibroid sclerosis and ossification of these 
structures this deformity is a permanent symptom. 

Fig. 50. 



^HBI 




/ 




Congenital curvature of the penis and adhesion to scrotum. (After Weir. ) 

Temporary curvature of the penis may occur during phimosis 
and paraphimosis and from chordee. 

Within the past twenty years, in which extremely large incisions 
into and over-dilatation of the urethra have been so extensively 
practised, it has not been uncommon to see many distressing cases 



150 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

of curvature of the penis, in some of which intromission was im- 
possible, while in others coitus could be indulged in with great 
difficulty and discomfort. In many of these cases the distress of 
the patient was increased by the resulting sexual debility, which 
in some cases amounted to impotence. As a rule, curvature of 
the penis, the result of intemperate instrumentation, is permanent 
and wholly refractory to medical and surgical treatment. 



FRACTURE OF THE PENIS. 

This accident is quite uncommon, and generally occurs in coitus 
and exceptionally during sleep. It may be complete, in which 
case the cavernous bodies and spongy body are totally broken or 
incomplete, in which condition one cavernous body or the spongy 
body alone may be fractured. 

The first symptom is a sudden stabbing pain, and then swelling 
of the organ rapidly supervenes. When the corpora cavernosa 
are involved the swelling is on the dorsum and sides of the penis, 
and, according to the amount of extravasation of blood, is large 
or small. Pain, distention, and unwieldiness are prominent symp- 
toms. In some cases the fractured ends have been found, and on 
motion crepitation was produced. Veazey 1 reports the case of a 
young man who, in violent coitus, fractured the penis, except its 
integument, so that the two fragments could be moved over each 
other, and when pulled apart a distinct sulcus could be felt. I 
have had under my care a similar case. 

Fracture of the corpus spongiosum may occur as the result of 
a blow on the penis when curved in chordee ; it more commonly, 
however, is the result of violent efforts in coitus, sometimes in the 
bridal bed, but generally as an incident in a drunken debauch. 
In the case of fracture of the spongy body the parts rapidly 
swell, owing to the escape of blood, and, unless prevented by the 
prompt use of the catheter, extravasation of urine occurs, in which 
even the penis is greatly swollen from the base to the glans. In 

1 New Orleans Medical and Surgical Journal, October, 1884. 



ORGANIC IMPOTENCE. 151 

cases of urethral rupture retention of urine is a frequent and 
troublesome symptom. The retention may occur as the result of 
swelling and the resulting pressure on the canal, or it may be due 
to the valve-like action of the torn mucous membrane. 

The local disturbance and the consecutive symptoms vary in 
different cases. In all there is more or less hemorrhage, and 
when the urethra is involved there may be, in addition , as just 
stated, extravasation of urine. Fever is usually present in a pro- 
nounced form, and in some cases pyaemia, even so severe as to 
cause death, supervenes. As local effects, abscess, destructive 
ulceration of the tissues, and gangrene may occur, in which events 
urinary or urethral fistulse may be left. 

Fracture of the penis is observed in young and old subjects. In 
advanced life the sheath of the corpora cavernosa is sometimes more 
condensed and brittle than normal, and it is more liable to frac- 
ture. I saw such a case in the person of a very old man, who, 
during sleep, rolled over on a very erect penis and broke the 
corpora cavernosa as sharply as if they had been cut with a knife. 

The prognosis of fracture of the penis varies according to the 
extent and seat of the injury. When the cavernous bodies, one 
or both, are fractured, the parts may heal, and erections may 
thereafter be perfect, or erection may only occur in the proximal 
part of the penis, while the distal part remains flaccid. Veazey 
noted in his case that this condition was present at first, but that 
later on perfect erections occurred. 

The outcome in cases of rupture of the corpus spongiosum is 
usually a traumatic stricture of rapid growth and much density. 

Treatment. In mild cases rest in the recumbent position and 
the application of cooling lotions or ice-water may be all that is 
necessary, except the introduction of a soft catheter to empty the 
bladder. In the severe order of cases when the extravasation of 
blood is extensive, it may be necessary to make a free incision, 
and then perform external urethrotomy and establish bladder 
drainage. Ulceration and gangrene of the parts should be treated 
on the regular surgical lines. All collections of pus should be 
incised and the parts antiseptically dressed. 



152 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

Rupture of the corpus spongiosum usually requires the regular 
passage of a catheter, and perhaps its retention for a longer or 
shorter period. Free incisions should be made when extravasa- 
tions of urine has occurred, and when blood-extravasation is 
extensive, particularly when it exerts injurious pressure. As the 
swelling in these cases is usually so great that the urethra cannot 
be reached and promptly stitched, it is necessary to await events, 
and when the stricture is forming to endeavor to restore the 
urethral calibre by the introduction of sounds, and, in the failure 
of this effort, to resort to internal urethrotomy. 



CHAPTER XIII. 

STERILITY IN THE MALE. 

It is only within the past twenty-five years that the subject of 
sterility in men has been carefully studied and that clear ideas 
have been entertained concerning it. In earlier years unfruitful 
marriages were generally, by common consent, ascribed to the 
fault of the wife, who in many instances was energetically and 
needlessly submitted to much gynecological treatment, discomfort, 
and trouble. In those earlier days, if a man seemed well devel- 
oped sexually, if he was able to copulate properly, and if he had 
what seemed to be normal ejaculations, he was deemed potent, and 
if he was married and without issue, the fault was not laid at his 
door. But with the advance in medical science, the condition of 
the semen and of the seminal tracts has been carefully studied, 
with the result of proving that in many cases, although to the 
unaided eye this secretion seemed normal, yet by the aid of the 
microscope it was found to contain unfertile spermatozoa or no 
spermatozoa at all, although all the other constituents of the secre- 
tion might be present. As a net result of the observations of many 
investigators, it may be stated, in general, that in cases of unfruit- 
ful marriage the husband is the sterile partner about one time in 
six. 

Two conditions have been found to be the cause of sterility in 
the male. The first is called azoospermatism, in which, although 
the man can properly perform the sexual act, his semen is unfer- 
tile, for the reasons : 1, that it is lacking in spermatozoa ; 2, that 
these highly vitalized bodies are of imperfect development ; or, 
3, that they cannot reach the sexual tract. When the cause of 
this condition is investigated it is found to reside in some struc- 
tural change in the testes and the epididymes, by which the secre- 
tory function of these glands is either destroyed, or temporarily 



154 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

impaired, or that an impediment is offered to the escape of the 
spermatozoa, either in the epididymes or in some part of the vasa 
deferentia. 

The second condition producing sterility in the male is called 
aspermatism, in which, although the power of normal coitus exists, 
there is no ejaculation of semen, or the quantity of semen is de- 
ficient, or its emission is imperfect or impeded. Aspermatism is 
caused by a blocking up of the sexual tract in some part between 
the seminal vesicles and the ampullar and the meatus urinarius or 
the preputial orifice. 



CHAPTER XIV. 

AZOOSPERMATISM. 

The term azoospermatisni is applied to that condition in which 
a man retains the power of copulation, while in his ejacula- 
tions spermatozoa are either wholly absent or present in small 
quantity, or they are so poorly developed, or functionally inactive, 
or uufertile that he is of necessity sterile. Azoospermatous men 
may, therefore, possess the potentia coeundi and lack the potentia 
generandi. In azoospermatisni the absence of spermatozoa is due 
to some abnormality of the testes or to some blocking up of the 
vasa deferentia as far up as their ampullation. Azoospermatism, 
therefore, differs decidedly from aspermatism, in which condition 
the obstructive changes take place in the seminal tract between 
the seminal vesicles and deferential ampullations and the meatus 
urinarius. 

Azoospermatism results from a variety of abnormal and morbid 
conditions of the testes. In the front rank of abnormal states are 
the various forms of testicular misplacement and of absence of 
the testes or some part of their excretory canals. Gonorrheal 
inflammation plays an important part in this form of disorder by 
the stenosing and destructive lesions which it produces in the 
epididymes, testes, and vasa deferentia. True azoospermatism is 
induced when the organs of each side are involved ; but in the 
event of the trouble being unilateral it then constitutes a menace 
to the man's future virility, since he has but one testis left, and 
the function of this one may be and is very frequently destroyed. 

Syphilis is very often an important factor in this condition, since 
it may attack any or all portions of the testis or cord. 

Chronic testicular inflammation, due to some lesion of the gen- 
ital tract or to some infective process, is very often the underlying 
cause of a man's sterility, which may also result from orchitis due 



156 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

to muscular effort or strangulation of the cord and gangrene of 
the testis. 

The functional activity of the testes may be so impaired, or 
even destroyed, by the existence of hydrocele or hematocele that 
a man is temporarily or permanently azoospermatous. 

Tuberculosis of the testis is a not uncommon cause of destruc- 
tion of the organ, while under various circumstances and in dif- 
ferent conditions atrophy of these glands may result in the loss 
of their function. Tuberculosis of the prostate and of the seminal 
vesicles and ampullations may so alter or poison the secretions of 
these organs that the spermatozoa are killed. 

While it is true that many of the conditions thus outlined may 
attack but one testis, in which event a man is not azoospermatous, 
there is always a liability that the second organ may become in- 
volved, either by the original morbid process or by one of different 
nature and origin. These considerations have convinced me that 
the subject of azoospermatism can best be satisfactorily presented 
by a clear and concise description of all abnormal states and 
morbid conditions which may lead to the impairment or destruc- 
tion of the functions of the testes and of their canals. 



ECTOPIA TESTIS. 

It is necessary to recall to mind that in cases of abnormal posi- 
tion of the testis, known under the general term ectopia, the organ 
is either retained in the abdominal cavity or it becomes misplaced 
in its descent. This condition is also called cryptorchism, espe- 
cially when both testicles are misplaced, and the bearers of this 
deformity are called cry p torch ids. 

Thus we find the testes in abdominal ectopia either near the 
posterior wall of the abdomen or in one of the iliac fossse. In 
cases of imperfect descent it may be retained : 1, in the inguinal 
canal ; 2, in the fold between the scrotum and the thigh ; or, 3, it 
may pass under Poupart\s ligament through the crural ring and 
become lodged in the thigh ; or, 4, it may pass down and become 
fixed in the perineum in front and to the side of the anus. 



AZOOSPERMATISM. 157 

These misplaced testes, all of which are usually abnormally 
small, seem to be rather prone to undergo malignant degeneration. 

Ectopia testis has been by some authors considered to be an 
undoubted cause of sterility, assuming that the function of the 
other or free testis has been damaged. Curling 1 reports several 
cases in which no spermatozoa were found in the semen after very 
careful microscopic examination. The facts of the case are, how- 
ever, as stated by Monod and Terrillon 2 and by Monod and 
Arthaud. 3 In early years the spermatogenetic power of the re- 
tained or misplaced organ is unimpaired, but as time goes on the 
tissues either decay by fatty degeneration or by fibroid infiltration, 
and the function of the gland is then destroyed. 

Ectopia of the testis, therefore, may lead to such disorganiza- 
tion of the gland that spermatozoa are no longer developed in it. 
If in such a case the other testis is in any way diseased or de- 
stroyed the bearer is sterile. This point is well brought out by a 
case reported by Godard, 4 in which a man having an undescended 
testis had a child by a mistress, and who, after an attack of epi- 
didymo-orchitis on the opposite side, was twice married and had 
no progeny. Many years after this man's semen was found to be 
destitute of spermatozoa. 

In the rare cases of congenital absence of the testes, or of part 
of the vasa deferentia, the subject is azoospermatous. 

Treatment. This consists in cutting down on the misplaced 
testis, if accessible, and in anchoring it by sutures in the scrotum. 

1 Diseases of the Testis. London, 1866, pp. 434 et seq. 

2 Traite des Maladies du Testicule, etc. Paris, 1889, pp. 45 et seq. 

3 Contribution de l'Etude des Alterations du Testicule Ectopique. etc. Arch. 
Gen. de Med., 1887, Tome ii. pp. 641 et seq. 

i Etudes sur la Monorchidie et la Cryptorchidie chez rhomme. Mem. de la 
Societe de Biologie, 1857, p. 105. 



158 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

CHANGES IN THE EPIDIDYMIS, TESTIS, AND VAS 
DEFERENS DUE TO GONORRHCEA. 

Gonorrhoeal Epididymitis. 

As a result of the gonorrhoeal process in some cases certain 
structural changes take place, principally in the epididymis, and 
also in the vas deferens, which either temporarily or permanently 
prevent the escape of spermatozoa from the testis. In these cases 
sterility may result if both epididymes are attacked, or if the affec- 
tion is unilateral and the other one is otherwise damaged. 

The most important post-mortem studies and microscopical ex- 
aminations into the testicular structures and into the condition 
of the semen in cases presenting these lesions has been made by 
Gosselin, 1 Liegois, 2 and Terrillon, 3 and their essays furnish a basis 
for the study of this subject. 

Gonorrhoeal inflammation usually attacks the lower part or tail 
of the epididymis or globus minor, and less commonly the head 
or globus major, and gives rise to an indurated mass which may 
obliterate the efferent canal, which at this part of the organ con- 
sists of one very much convoluted tube. When this condition is 
produced no spermatozoa can pass into the vas deferens so long as 
it lasts. If the head of the epididymis is attacked with indurating 
hyperplasia, there is a chance that some of the numerous vasa 
efferentia may not be involved, in which event the escape of sper- 
matozoa may not wholly be prevented. For these reasons, there- 
fore, induration of the tail of the epididymis is a much more 
serious matter than implication of its head. 

In cases where obliteration of the spermatic canal has occurred, 
even when both sides are attacked, no perceptible change seems to 
take place in the testes. 

1 Nouvelles Etudes sur 1' obliteration des Voies Spermatiques et sur la Sterilite 
consecutive a l'epididy mite bilaterale. Arch. Gen. de Med., September, 1853. 

2 Influence des Maladies du Testicule et de Fepididyme sur la composition du 
Sperme. Annales de Dermat. et de Syphiligr., 1869, pp. 410 et seq. 

3 Des alterations du Sperme dans l'epididymite blennorrhagique. Ibid., 2d 
Series, Tome i. pp. 439 et seq. 



AZOOSPERMATISM. 159 

In cases where both epididynies are attacked patients seem to be 
sexually unaffected, being capable of coitus and having complete 
erections and ejaculations. The semen, however, is destitute of 
spermatozoa, and, therefore, is unfertile. 

In the early stage of this form of testicular trouble the semen 
is less viscid than normally, and it has a yellowish or yellowish- 
green tint, due to the admixture of pus-cells and granular globules, 
the origin of which is not known. 

Terrillon observed this yellow tint of the semen in a case of 
unilateral induration of the spermatic canal, and when this fluid 
was examined under the microscope spermatozoa were seen vigor- 
ously wriggling around among pus-cells. 

As the induration in bilateral cases grows older and necessarily 
becomes more stenosing, the pus-cells gradually disappear, but the 
spermatozoa do not reappear. The man, the ref ore, though capable 
of coitus, is sterile. When, however, one testicle has remained 
unaffected the bearer possesses the power of fecundation. 

It has been claimed by some authors that gonorrhoea^ tuber- 
cular, and other morbid affections of one testicle or epididymis 
may in some occult way so affect its fellow that it also becomes 
incapable of producing spermatozoa, and that as a result the man 
becomes sterile. There is, however, no scientific evidence to sup- 
port this contention, which probably is the outcome of faulty clin- 
ical investigation and deduction. 

Liegois has very clearly shown by his studies that in propor- 
tion as the induration of the globus minor softens and disappears 
spermatozoa show themselves in the semen in increasing numbers 
until the normal condition of that fluid is reached. This author, 
among three hundred cases of epididymitis, did not observe a single 
case of genuine atrophy of the testis, although he observed a slight 
diminution in volume in six or seven instances. In only eight 
cases did he note loss of virile power, while in several it was 
notably increased. 

The conclusions, therefore, warranted by the foregoing consid- 
erations areas follows : 1. In all cases of unilateral epididymitis 
treatment should not cease with the decline of the acute stage, but 



160 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

active measures should be taken to cause the absorption of the 
induration. 2. When bilateral epididymitis exists, even if of pro- 
longed duration, energetic and long-continued treatment should be 
adopted, with the hope of dissipating the induration. 3. In cases 
of recent involvement much hope may be entertained of perfect 
cure. 

My experience has convinced me that the existence of chronic 
gonorrheal epididymitis, unilateral or bilateral, even with unfer- 
tile semen, may in many instances be so much relieved that virility 
is restored to the man. 

Luckily for the human race, the tendency in most cases of gon- 
orrheal epididymitis is toward resolution, at any rate, to the degree 
of rendering the spermatic canal patulous. 

Post-mortem investigations in cases of gonorrheal induration 
of the epididymis have confirmed the facts brought out by clinical 
observation. Hardy endeavored to force an injection-fluid through 
the tail of an indurated epididymis, and failed. 1 In like manner 
Delaporte 2 was unsuccessful in a case of epididymitis which had 
only existed five weeks. 

Gonorrheal Orchitis. 

Though its occurrence is denied by some authors, there can be 
no doubt that in some cases of gonorrheal epididymitis there is 
true inflammation of the testis proper. In the majority of cases, 
however, of so-called gonorrheal epididymo-orchitis there is simply 
a hypersemic and quasi-inflammatory condition analogous to the 
congestion of the prostate, which may occur in acute gonorrheal 
posterior urethritis. 

As a rule, testicular involvement in gonorrheal epididymitis 
quickly disappears, and the gland seems normal upon palpation. 

In some cases, however, chronic parenchymatous orchitis is de- 
veloped, which may lead to the disorganization of the gland. The 

1 Etudes sur l'inflammation du testicule et principalement sur Pepididymite et 
l'orchite blennorrhagique. These de Paris, 1860, p. 15. 

2 De l'orchite aigue blennorrhagique. These de Paris, 1866, p. 12. 



AZOOSPERMATISM. 161 

essential change is cell-proliferation into the connective tissue 
around the seminal tubules, as a result of which the development 
of spermatozoa ceases and the tubules become filled with granular 
matter and cholesterin crystals. While at first the gland is more 
or less increased in size, as the degenerative changes grow old, 
condensation and atrophy occur even to the extent of destroying 
all evidence of glandular structure and transforming the organ 
into a mass of dense fibrous tissue. I have seen two well-marked 
examples of atrophy of the testis from acute gonorrhoea, and Rona 1 
has published the history of a very interesting case. 

Gonorrhoeal Funiculitis, or Deferentitis. 

In some cases the gonorrhoeal process does not reach the epidid- 
ymis, but centres itself in a segment of the vas deferens, usually 
near the testis, or at any part up to the external abdominal ring. 
In such cases a goodly sized, round or oval tumor is formed, which 
is the seat of pain. After the inflammation subsides a hard nodule 
is left, which may block up the calibre of the canal, and if the 
resulting stenosis is permanent spermatozoa cannot pass from the 
testis. When this condition exists in the course of both vasa 
def erentia the bearer is sterile. Such cases, however, are very rare. 

The vas deferens may be attacked within the pelvis, and more 
or less damage to its lumen may follow. Instances of this affec- 
tion are very uncommon. 

Treatment. Active efforts should be made to cause the absorp- 
tion of the cellular infiltration, wherever it may be. In some cases 
repeated small blisters with cantharidal collodion are beneficial. 
As a rule, strapping the testis should be practised until it is 
demonstrated that good results follow or that no effect is pro- 
duced. Applications of mercurial ointment, of iodine ointment, 
of iodide of lead ointment (one drachm to one ounce of cerate), 
or of ichthyol ointment (one drachm to two drachms of cerate) 
may be tried, and their use should be persisted in. These prepa- 
rations may be spread on layers of absorbent cotton, which are 

1 Monatshefte fur Prak. Dermat, 1886, Band v. pp. 360 et seq. 

11 



162 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

placed over the scrotum, over which is one thickness of gutta- 
percha tissue, and the whole held up snugly by a suspensory ban- 
dage. 

Iodide of potassium may be given internally. 

In every case the condition of the urethra should be ascertained, 
and if chronic inflammation be present it should be thoroughly 
treated. 



CHANGES IN THE EPIDIDYMIS, TESTIS, AND VAS 
DEFERENS, DUE TO SYPHILIS. 

Syphilitic Epididymitis. 

Syphilis may attack the epididymis, both in its early and late 
stages. In the early months of the infection it is not uncommon 
to find the globus major, and less frequently the globus minor, of 
the testis to be swollen, hard, and moderately painful, especially 
when compressed. This condition also occurs at any time during 
the first and second years of the disease. 

The size of the tumor, which has a smooth surface and firm 
consistency, varies between that of a pea and a hickory-nut. Un- 
influenced by treatment, this indurated nodule will remain in an 
indolent condition for a long period, and will ultimately produce 
disorganization of the head of the epididymis. But if local and 
general treatment is promptly adopted, resolution soon follows, 
and the integrity of the parts is restored. 

In some cases both epididymes are attacked, either simultane- 
ously, or, as more commonly occurs, after a longer or shorter 
interval. 

It sometimes happens that an epididymis previously indurated 
by gonorrheal inflammation becomes attacked by syphilis, in 
which event resolution may be very slow, and in the end some 
condensation of tissue may remain. 

The diagnostic point that gonorrhoea attacks the tail of the 
epididymis, and that syphilis is more prone to invade the head, 
may be observed in the greater number of cases. 



AZOOSPEBMATISM. 163 

In late secondary and in tertiary syphilis the epididymis is some- 
times attacked in a slow, painless way by a chronic infiltrative 
process, which leads to a smooth or nodular bulbous expansion 
of the affected segment, usually the head of the appendage. 

This late form of syphilitic epididymitis is usually unilateral, 
but it may be bilateral. Tertiary syphilitic inflammation may 
attack an epididymis the seat of gonorrhoeal induration, and then 
stenosis of the spermatic canal is to be feared. Late syphilitic 
epididymitis does not yield to treatment as promptly as the early 
form does ; therefore, it is important that medication should be 
commenced as early as possible, and pushed with care and vigor. 

In very rare cases syphilitic nodules form in the vas deferens 
in the scrotum, and they may, if left aloue, lead to stenosis of that 
tube. 

When occlusion of one spermatic canal is produced by the fore- 
going processes a man's virility is not destroyed, provided the 
other testis is competent ; but if permanent stenosis of both sper- 
matic canals is developed, sterility inevitably follows. In these 
cases much hope can be entertained, hence treatment should not 
be precipitately abandoned. 

Syphilitic Orchitis. 

Late in the secondary and during the tertiary period the body 
of the testis may become attacked by a slow, painless, and in- 
sidious fibroid or gummatous infiltration. The organ becomes 
uniformly swollen, hard, firm, less sensitive than normal, and 
usually smooth on its surface. In some cases large nodular masses 
may be found in the organ as a result of gummatous infiltration. 

As a rule, the testis at first retains its normal shape, but as 
time goes on it enlarges very considerably, even to the size of a 
big fist, and becomes of a decidedly pear- shape, or ovoid or glob- 
ular. Usually one testis, but not infrequently both glands, are in- 
volved. (See Fig. 51.) 

This form of orchitis, or sarcocele, as it is called, runs a chronic, 
uneventful course if left to itself ; but it will yield in a surprising 



104 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

manner if treatment is instituted early. The danger in the affec- 
tion is that the seminal lobules will be destroyed by the fibroid or 
gummatous tissue which develops in the fibrous stroma in which 
they lie. When this occurs the development of spermatozoa in- 
evitably comes to an end. In addition, the efferent tubules may 
be destroyed by fibroid stenosis or degeneration. Therefore, this 

Fig. 51. 




Double syphilitic orchitis, or sarcocele. 

affection is a very serious one, as it tends from the first to destroy 
the spermatogenetic capacity. Degenerative changes may occur 
and abscess may be produced, or the testis may be transformed 
into a fungating mass — fungus testis. 

In exceptional cases the testis in tertiary syphilis becomes sud- 
denly swollen and painful, and presents points of resemblance to 



AZOOSPEBMATISM. 165 

gonorrhoeal epididymo-orchitis, except that the epididymis is very 
rarely attacked. This syphilitic orchitis 1 of brusque invasion is 
usually attended with pain in the groins and loins. The acute- 
ness and severity of the symptoms may last a week or two, and 
then the process gradually subsides until the typical indolent con- 
dition is observed. In these acute cases involvement of both 
glands is to be very much feared. Effusion of fluid into the tunica 
vaginalis is sometimes to be found in cases of this testicular lesion. 

This form of orchitis is very likely to lead to destruction of one 
or both testes and to partial or total sterility. 

Nearly all patients suffering from syphilitic sarcocele become 
very anxious and apprehensive, fearing that as a result they may 
become sterile. When but one testis is attacked the patient's 
ejaculation will contain fertile spermatozoa, provided the other 
gland is unaffected and competent. Even when both glands are 
attacked it is often surprising to see how promptly resolution 
occurs and how soon the semen again becomes fertile. I have 
seen many such cases, in which, after bilateral syphilitic sarcocele, 
a cure has been produced and the man has begotten healthy chil- 
dren. In these cases, therefore, it is well to be very hopeful, and 
to press the treatment as vigorously as possible, since a perfect 
cure and restored virility may occur even when the case appears 
desperate. It seems remarkable that the seminiferous tubes may 
be so profoundly and chronically affected, and yet they may regain 
their function perfectly. However, when syphilitic sarcocele has 
existed for very long periods, such as one or several years, there 
is danger of the destruction of the function of the organ, and that 
od resolution atrophy may result. 

In all cases in which syphilitic sarcocele is complicated with 
exuberant fungoid development the spermatic function of the 
gland is destroyed. 

1 Broca has published an interesting case of this kind (Syphilis testiculaire 
bilaterale a debut brusque et douloureux : Gazette Hebdom., 1883, Tome x. pp. 181 
et seq. ), and Carsine has published a number of cases (Du Sarcocele Syphilitique 
a debut innammatoire et douloureux : These de Paris, 1886) in which the testic- 
ular lesion was accompanied by severe secondary manifestations. 



166 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

There is a class of quite rare cases, to which attention was first 
directed by Laroyenne, 1 of syphilitic men who, without perceptible 
lesion of the testes, are sterile. In these cases there is no history 
of testicular involvement, nor are there any symptoms pointing to 
disturbance in the gland. I have examined the semen in several 
of these cases, and have been struck by the entire absence of sper- 
matozoa in that fluid. This azoospermatism may be seen in persons 
in the secondary stage of syphilis and in those in whom the infec- 
tion had not shown any evidence for a few or many years. Laro- 
yenne thinks that in these cases syphilitic cell-infiltration of a mild 
degree has so compressed the tubules that the function of sperma- 
togenesis is destroyed. This view is also entertained by Bryson, 2 
who, in a series of cases, found absence of spermatozoa in the 
seminal fluid. 

As a rule, in this form of syphilitic azoospermatism treatment 
fails to afford any relief ; but in one case I was surprised and 
pleased at the reappearance of spermatozoa after an absence of 
three years, in consequence of a prolonged and vigorous course of 
treatment. 

Syphilitic Funiculitis, or Deferentitis. 

Syphilitic infiltration in and around the vas deferens is very 
rare, and shows itself as nodular or moniliform swellings of indo- 
lent course. If left to themselves these lesions undergo degen- 
eration and the lumen of the canal is occluded. 

Hereditary Syphilis of the Testis. 

In syphilitic infants and young children the testicle may become 
indolently and painlessly swollen to the size of a pigeon's egg or 
of a walnut. The epididymis may also be synchronously attacked, 
and in very rare instances the vas deferens is enlarged to a greater 
or less extent. These testicular alterations, due to hereditary 

1 De l'infecondite* d'origine syphilitique. Lyon Medicale, 1875, No. 4. 

2 Syphilitic Azoospermism. St. Louis Courier of Medicine, 1882, vol. vii. pp. 
495 et seq. 



AZOOSPEBMATISM. 167 

syphilis, may, if promptly treated, end in full resolution. In 
some cases, however, atrophy, necrosis, abscess, and fungoid de- 
generation lead to the incompetence of the gland as a factor in 
the sexual function. In these cases a round or irregular nodule 
of fibrous tissue remains, and the virility of the person, should 
he reach puberty, depends upon the integrity of the remaining 
testis. Unfortunately, in hereditary syphilis both testes frequently 
may be attacked, and with their destruction the ultimate sterility 
of the patient is inevitable. In some cases of syphilitic orchitis in 
the young subject tubercular infection attacks the affected tissue, 
and thus adds a factor of malignancy to the case. 

Lewin 1 reports the case of a lad, eighteen years old, who was 
puerile in demeanor and very boyish-looking, whose testicles were 
of the size of those of an infant, as a result of hereditary syphilis 
in infancy. Reclus 2 speaks of the case of a patient (age not given), 
considered by Parrot and Fournier to be the victim of hereditary 
syphilis, in whom a testis of the size of a small nut, and of great 
firmness, was present. I have seen a case in which the gland 
was reduced to a small mass of fibrous tissue. When we find 
such a sequela in an adult the suspicion of antecedent hereditary 
syphilis of the testicle is warranted. 

Treatment. In all cases of syphilis of the testis and epididy- 
mis an energetic and prolonged treatment by mercury and iodide 
of potassium should be adopted. In these cases the local use of 
mercury in the form of blue ointment should be instituted at once 
and persisted in. It is a good rule to begin with goodly doses of 
the iodide of potassium (10 to 20 grains ter in die), and to increase 
the quantity until two or three drachms are taken three or four 
times a day. This drug may also be given in combination with 
biniodide of mercury — the so-called mixed treatment. Testicular 
lesions in infants should be treated in the same manner, except 
that smaller doses should be given. Many brilliantly successful 
results follow active treatment. 

1 Berl. klin. Wocliens., 1876, Xos. 2 and 3. 

2 De la Syphilis du Testicule. Paris, 1882, pp. 149 et seq. 



168 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

CHRONIC ORCHITIS AND EPIDIDYMITIS. 

The testis and the epididymis are liable to be attacked by such 
a degree of chronic inflammation in young, middle-aged, and old 
subjects that the function of the gland may be destroyed by the 
indurating and atrophic processes which supervene. In many of 
these cases there has existed as a starting-point gonorrhoeal epi- 
didymitis, or epididymo-orchitis ; in some, however, the gland 
had previously been healthy. 

In some cases of chronic posterior urethritis and of stricture of 
the urethra, usually in careless sexually indulgent subjects, the 
epididymis is attacked by a mild form of inflammation, which 
does not cause the patient to go to bed or the epididymis to be- 
come much swollen or painful. Such an attack usually soon 
subsides, and is followed at a greater or less interval of time by 
a recrudescence, which in its turn is followed by another attack, 
and so the case continues for years. Some relapses are more severe 
and inflammatory than others. When examined, such an epidid- 
ymis is found to be enlarged usually in its whole length, the swell- 
ing being quite uniform and diffuse, and not nodulated at any 
point. Thus is produced a hard, firm, perhaps painless, sclerotic 
crescent, which is attached to the back and upper and lower part 
of the gland. The lesion not being of a tubercular nature, degen- 
erative changes, such as abscesses and necrosis, are not observed, 
but as time goes on the sclerosis gradually destroys the efferent 
spermatic tubes and produces azoospermatism of one and not in- 
frequently of both sides. The testis may become rather larger 
than normal or it may decrease in size. As a rule, patients thus 
affected being young and well, and observing for a long period 
no diminution in their sexual desires and in their ability for copu- 
lation, pay little heed to their testicular trouble. Later on, in cases 
of double epididymitis or epididymo-orchitis, the sexual appetite 
and the capacity for coitus may begin to wane, and the affection 
becomes a source of anxiety and apprehension. In the case of 
unilateral involvement there may be no functional impairment 
unless the unaffected testis becomes diseased from any cause. 



AZOOSPERMATISM. 169 

This form of chronic epididymo-orehitis being so persistent, 
so liable to undergo exacerbation, and so rebellions to treatment, 
is really a serious affair, and it calls for careful local and urethral 
treatment. 

The clinical picture above portrayed will apply to cases of 
young and old subjects usually having chronic gonorrhoea or 
stricture of the urethra, in whom it is necessary to pass for long 
periods of time urethral instruments ; also to cases in which lith- 
otrity, litholapaxy, and lithotomy have been performed. In these 
cases, however, abscess of the testis may occur. 

In some old men having hypertrophy of the prostate, cystitis, 
and that low-grade form of chronic urethritis which is not 
uncommon, a slow, usually painless fibroid enlargement of the 
whole epididymis, and perhaps of the testis, may not uncommonly 
be observed. When double, this affection soon extinguishes the 
process of spermatogenesis, and coincidently the sexual desire may 
become less keen. When the trouble is unilateral there may be 
no perceptible impairment of the sexual function for a long time. 

The tendency of this affection is to produce permanent sclerosis 
of the parts attacked. 

ORCHITIS AND EPIDIDYMO-ORCHITIS, DUE TO 
GENERAL INFECTIVE PROCESSES. 

Testicular inflammation is not uncommonly observed as a com- 
plication of a number of infective processes, and it may lead to 
such structural changes that the integrity of the testis, of the 
epididymis, or of both, may be destroyed. These infective testic- 
ular lesions, as a rule, attack but one gland, but it is not uncom- 
mon to see both glands affected. As a rule, the testis is the part 
attacked, and with it the epididymis may be involved. It is not 
common to find infective epididymitis without involvement of the 
testis. 

Mump Orchitis. 

During the course of mumps the testicle, especially in young 
subjects, may be attacked by severe inflammation, and the clinical 



170 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

picture of blennorrhagic epididymo-orchitis may then be counter- 
feited. The invasion of this affection is brusque and its course 
rapid. Occasionally, the two testes are attacked. Full resolu- 
tion may occur, but it is not at all uncommon to observe total 
atrophy of a gland, and, exceptionally, of both glands. Many 
men become sterile owing to the destruction of one testis by 
mumps and of the other by some other morbid change. The 
reciprocal relation between the testes and the parotid glands is 
shown in certain rare cases, in which, after the removal of these 
glands, the parotids become acutely swollen and inflamed. 

Tonsillar Orchitis. 

This condition may occur during the course of tonsillitis, with 
acute invasion and usually with prompt resolution. Abscess may 
destroy the testis. 

Variola Orchitis. 

In some cases of smallpox the testis, epididymis, and tunica 
vaginalis may become rapidly and severely inflamed. Resolution 
usually occurs, but in some cases atrophy or abscess of either or 
all of these structures ensues. 

Scarlatina Orchitis. 

This form of orchitis may occur in children and adolescents, 
and it is usually of an active type. Resolution may take place, 
but atrophy may result. 

Malarial Orchitis. 

During the course of malaria the testis may become inflamed, 
even in subjects who have not had gonorrhoea and its testicular 
trouble. Iu the cases thus far reported it has been noted that 
exceptionally atrophy of the testis and induration of the epidid- 
ymis have followed this malarial phlegmasia. 



AZOOSPERMATISM. 171 



Grip Orchitis. 



Involvement of a testis which previously had been healthy, or 
which had been the seat of gonorrheal inflammation, has been 
observed in quite a number of instances. Resolution usually 
occurs, but atrophy, epididymal induration, and gangrene are 
liable to follow. 

During the course of whooping-cough, pneumonia, typhoid 
fever, pyaemia, and of grave phlegmonous inflammation of bones, 
the testis and perhaps the epididymis may become the seat of in- 
flammation. In such cases resolution may take place or degen- 
eration of the testis or of the epididymis may be produced. 

The danger of these infectious testicular inflammations lies in 
the fact that they occur chiefly in young subjects, and that when 
they are severe destruction of the gland is complete. Should the 
unaffected testis later on become involved by one of the many 
morbid conditions which are liable to attack it, the result is ster- 
ility in its bearer. 

The treatment is that used for gonorrheal epididymo-orchitis. 

ORCHITIS DUE TO MUSCULAR EFFORT. 

This form of traumatic orchitis is moderately common. It 
may be a simple and ephemeral condition, or such changes may 
be produced by the injury that the epididymis may be much 
enlarged and indurated, or the testis may be so disorganized that 
atrophy may result. In either of these events unilateral azoosper- 
matism may follow the injury to the epididymis or the testis. 

The clinical picture of orchitis from muscular effort is that of 
gonorrhoeal epididymo-orchitis, usually with a preponderance of 
the testicular trouble. Under the influence of rest and suitable 
local applications resolution usually occurs quite promptly, but 
the testis may remain tender and somewhat swollen for some time. 
Terrillon 1 reports a case of this form of orchitis in which atrophy 

1 Annales des Mai. des Org. Gen.-urin., 1885, Tome iii. p. 239. 



172 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

occurred, and this process was attended by so much pain that 
castration was resorted to. 

In all probability orchitis from muscular effort is due primarily 
to sudden and strong abdominal pressure upon the spermatic plexus 
of veins in persons who have lifted heavy weights, who have slipped 
with violence, or who by any means have been rudely shaken, as 
in jumping a great distance, or even hurriedly alighting from a 
car in motion. Tenuity of the walls of the veins may be the 
underlying condition favorable to the development of this accident. 

It is only in severe cases that this traumatism may cause degen- 
eration of the testicle, which of itself would not lead to sterility 
if the other testis be sound. The lesion produced in the testis 
and epididymis is, first, effusion of blood, and, second, the changes 
produced by the compression thus exerted. 

The treatment is the same as that employed in acute epididymo- 
orchitis. 

STRANGULATION OF THE TESTIS AND EPIDIDYMIS 
FROM TORSION OF THE CORD. 

This form of traumatism is very uncommon, and occurs in 
subjects (mostly young ones) whose testicular apparatus is some- 
what malformed. There is usually a history or evidence of 
undescended or imperfectly descended testis ; consequently, as a 
rule, the swelling is found in the inguinal canal or just within the 
upper part of the scrotum. There are present localized swelling, 
oedema, and redness, and such subjective symptoms as may point 
to strangulated hernia, traumatism, or appendicitis. The position 
and quite sharp localization of the tumor, the absence of the testis 
from the scrotum, and the history of the case will usually point 
to its nature. The diagnosis, however, is, as a rule, confirmed 
when an exploratory incision has been made. Then the testis 
and epididymis are found to be swollen, of a deep blue or even 
black color, and sometimes they are gangrenous. In most cases 
the testis is entirely destroyed. 

In some cases excessive and violent strain causes a twisting of 
the cord, which produces this trouble. In others no exciting cause 



AZOOSPERMATISM. 173 

can be ascertained. The twist of the cord may be partial or com- 
plete, or the cord may be twisted several turns. The essential 
and underlying cause of torsion of the cord is disturbance in the 
development of the vaginal process of the peritoneum, in which 
the mesorchium is either too slender or too long, and hence does 
not give the testis the necessary amount of fixation. The mesor- 
chium then allows greater movement than normal, and the testis 
may, as a result, encounter difficulty in entering the inguinal canal 
and impediment in traversing it. When it is in the inguinal canal 
the flat condition of the. testis militates against its replacement 
and renders this impossible when inflammation has been estab- 
lished. In the scrotum the torsion may be reduced. Usually 
such a testis requires prompt extirpation. Provided the other 
testicle is competent, the sterility of the man is not lost. 

Hydrocele. 

In some cases of old hydrocele such pressure is exerted upon 
the testis and the epididymis that the spermatogenetic function is 
much impaired, and it is even temporarily suspended. In some 
old cases in which the tunica albuginea and the epididymis are 
much thickened and contracted by fibrous hyperplasia, fertile sper- 
matozoa are no longer produced. 

Lannelongue 1 and Marimon 2 have in cases of old and volumi- 
nous hydrocele found such alterations in the structure of the epi- 
didymis and the efferent tubes so injuriously compressed that the 
escape of semen was profoundly interfered with. A very impor- 
tant fact has been noted by Roubaud 3 in the case of a young man 
who had very large double hydrocele. He was then sterile, and 
no spermatozoa were found in his semen. After puncture of the 
two sacs spermatozoa reappeared in the semen, disappeared when 
they became filled and distended again, and reappeared after a 
second tapping of the two hydroceles. 

1 Bulletin de la Soc. de Chirurgie, 1873, 3d Serie, Tome ii. p. 421. 

2 Kecherches sur l'Anatomie pathologique des grosses Hydroceles. These de 
Paris, 1874. 

3 Traite de l'lmpuissance, etc., 1876, p. 576. 



174 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

Out of twenty-three cases of hydrocele in which the semen was 
examined by Lannelongue no spermatozoa were found in five. 

Desmaroux 1 reports the case of a man, fifty -seven years old, 
who had double hydrocele and was sterile, but who became potent 
after puncture and iodine injection of the tunica vaginalis. It is 
well, therefore, not to forget that hydrocele may be at least a tem- 
porary and, exceptionally, a permanent cause of sterility. 

Treatment. Palliative measures consist of tapping the vaginal 
cavity as often as it becomes full. In all cases, especially where 
the function of the testis is impaired by hydrocele, the best pro- 
cedure is to perform Yon Bergmann's operation, in which all the 
parietal layer of the tunica vaginalis is cut away. 

Hematocele. 

In severe cases of hematocele such damage is inflicted upon 
the testicle and such injury is produced by the effusion of blood 
and the subsequent changes that the function of the gland may 
be destroyed. If its mate, however, is competent, sterility does 
not necessarily follow, but in case it is damaged the bearer is 
sterile. 

Kocher 2 has shown that the seminiferous tubules may be altered 
and even obliterated by hyperplasia of fibrous tissue, and that 
the whole gland may undergo fibroid degeneration after hema- 
tocele. Pilliet 3 has clearly shown that the sclerosis begins in the 
tunica albuginea, and spreads inward and invades the coats of the 
tubes and the vessels, and thus destroys the glandular structure. 
It is well, therefore, to bear in mind that besides being a source 
of pain and annoyance hematocele may, if left untreated, lead to 
such damage of the testis that its function will be wmolly lost. 

Treatment. In recent acute cases rest in bed, suspension of 
the scrotum, and the application of cooling lotions are necessary. 

1 Gazette des Hopitaux, 1883, Tome lvi. p. 762. 

2 Die Krankheiten der Miinnlichen Geschlechtsorgane. Stuttgart, 1887, pp. 
100 et seq. 

'■'' Note sur l'£tat du Testicule dans 1' Hematocele Vaginale. Compt. rend, du 
Soc. de Biologie, 1887, Series 8, Tome iv. pp. 324 et seq. 



AZOOSPERMATISM. 175 

When fluctuation can be distinctly discovered it is well to incise 
the part (after proper surgical preparation) and then to pack it 
with iodoform gauze. It is always well not to operate until the 
indications therefor are very clear. 

In chronic cases compression may be tried and mercurial or 
ichthyol ointment may be employed. When the tumor remains 
unchanged and uninfluenced by treatment it may be necessary to 
resort to Volkmann's operation for hydrocele. When the tumor 
is of very large size or when testicular disorganization is evident, 
it may be necessary to remove the organ. 



TUBERCULOSIS OF THE TESTIS. 

Tubercular infiltration is one of the most common affections 
which attack the testis and destroy its function. It is observed 
chiefly at and during puberty and in adult life, but may be found in 
infants, and much less frequently in middle-aged and elderly men. 

In all probability, tubercle of the testis is developed seconda- 
rily to some other more or less remote focus of infection of the 
body, and it is chiefly noted as being found in association with 
tuberculosis of the prostate, seminal vesicles, and bladder and 
ureters and kidneys. Though some cases, from a clinical stand- 
point, seem to be instances of primary testicular tuberculosis, it 
is not well to venture such a diagnosis with much positiveness, 
since lurking and perhaps dormant foci of infection may exist in 
some part of the body which can only be detected by post-mortem 
examination. 

As to the avenues by which the testis is invaded, it may be 
stated that clinical, anatomical, and pathological facts point to the 
bloodvessels as the carriers of the infective material. 

There is no scientific evidence at hand in favor of the view 
that infection through the urethral canal may occur and lead to 
testicular invasion. 

There is good reason for supposing that infection of the seminal 
vesicles and prostate may occur through the vesico-rectal peritoneal 
fold from tuberculosis of the peritoneum. 



176 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

In clinical practice we find two quite clearly marked forms of 
tubercle of the testis — namely, the acute and the chronic forms. 
Besides these forms we find mixed varieties, in which acuity and 
chronicity are blended. 

The acute form of tuberculosis of the testis presents somewhat 
the same clinical picture as is offered by acute gonorrheal epidid- 
ymitis. The patient may have given evidence of tuberculosis in 
some other and perhaps remote organ ; he may or may not have 
complained of bladder, prostate, or urethral disorder j and he may 
or may not have suffered from gonorrheal epididymo-orchitis. 
He may have previously enjoyed good or fairly good health, or 
the testicular lesion may appear as the only local evidence of dis- 
ease in a man who is pale, weak, and sickly, and who, perhaps, 
has within a short time lost flesh. In many cases traumatism 
seems to be the exciting cause. 

Usually the first symptom is pain seated in the head or the tail 
of the epididymis, and very soon the segment involved swells to 
considerable size. In some galloping cases the whole epididymis 
is much swollen in all directions, is either spontaneously painful 
or on slight pressure, and is covered with an acutely inflamed area 
of scrotal tissue in a day or two. In other cases several days, or 
even two or three weeks, elapse before such an acute condition is 
reached. In these cases there is usually more or less fever and 
malaise. 

When palpated in this state the epididymis usually does not 
present any diagnostic points, and the conclusion may be reached, 
if there is any evidence of urethral discharge, that the case is 
one of gonorrheal epididymo-orchitis in the declining or chronic 
stage. When the entire absence of any urethral discharge or 
affection is rendered clear the suspicion of tubercular invasion 
may be entertained. 

In a few days, or in a week or two, upon the subsidence of the 
severe inflammatory reaction (in cases in which an abscess has not 
been formed, and in which vaginalitis has not developed), the 
surgeon can carefully examine the organ, and then, or perhaps 
later, a nodular or bossy condition of the head and tail and per- 



AZOOSPEBMATISM. 177 

haps of the body of the epididymis may be clearly made out. 
At this time the testis may appear uninvolved, but later on it 
may become more or less enlarged, and on its surface small or 
large nodulations, just as if small shot or split pease were seated 
in the tissue, can be felt. 

It sometimes happens that the seminal fluid becomes of a rose 
color from blood admixture, probably derived from some part of 
the testis. 

Abscess may sooner or later develop, usually at the head of the 
epididymis, and also at the tail. When the tail of the epididymis 
is attacked it is not uncommon to find a mass of suppurating tissue 
about an inch or less from it and connected by a fibrous strand in 
the loose scrotal tissue. These extra-epididymal abscesses seem 
to be due to infecting pus which escapes from the involved epi- 
didymis. 

Abscess is the direct outcome of the caseation and softening of 
the tubercular inflammation. The non-vascular cellular nodules 
produced by the infective process, and the infiltration which sur- 
rounds, compresses, and destroys the seminal tubules and leads to 
a chronic diffuse orchitis, break down and give issue through one 
or several fistula? to a thin fluid streaked with pus and small 
grumous masses. The scrotal wall becomes of a deep red, even 
of a bluish-red color, and the orifices of the fistula} look very 
unhealthy. In the cases thus briefly described there is usually 
more or less destruction of the testis proper, but the function of 
the gland is promptly destroyed by the deadly infective invasion 
which attacks it in its centre and on both flanks. The develop- 
ment of tuberculosis of the epididymis is well shown in Fig. 52, 
and its extensive invasion of the testis proper is admirably por- 
trayed in Fig. 53. One testis may be thus attacked, but not very 
frequently the other one is sooner or later involved. 

In the chronic form of tuberculosis of the testis many clinical 
pictures are presented. In some cases, in apparently healthy or 
in sickly-looking subjects, with or without coexisting urethral, 
prostatic, and vesicular involvement, the epididymis (tail or head) 
swells painlessly, and the patient by accident discovers a small 

12 



178 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

Fig. 52. 




a 



Tuberculosis of the testis. 
The larger portion of the epididymis lies on the right side. a. Cheesy epi- 
didymis, b. Whitish mass occupying the mediastinum. c. Isolated tubercle 
with cheesy centre, d. Small cyst at the summit of globus major, e. Larger and 
smaller opaque spots scattered over the surface of the testicle. 

pea-sized or hickory nut-si zed nodule of irregular outline. This 
condition may slowly increase, and as it does the infiltration 
becomes more rugose upon its surface, and it may extend to the 

Fig. 53. 




Tuberculosis of the testis. 
The testicle is cut so that the larger part of the epididymis lies in the right 
half. a. Swollen and cheesy epididymis, b. Mass of confluent tubercles at the 
mediastinum, extending outward into the testicle and united above with the 
globus major, c. Larger and smaller tubercles, some with cheesy centres, in the 
testicle tissues. 



AZOOSPERMATISM. 179 

whole epididymis, converting it into a fibrous mass. In this 
painless, indolent state it may remain for a long time — months 
or years — or caseation, softening, and fluctuation may be discov- 
ered, or abscess or fistula may develop. On removal of such a 
testis the epididymis is found to be very tough and fibrous, with 
here and there cavities in which degeneration has occurred. Very 
often no evidence of invasion of the testis can be found. 

In other chronic cases there may be synchronously observed 
separate nodules of small or large size in the head and tail of 
the epididymis, with what is then most common, the involvement 
of the whole mediastinum testis. In these cases the disease may 
remain latent and indolent for varying periods (often quite long 
ones), or exacerbations may occur, and the case in its course may 
then resemble those of acute development. In general, however, 
the infective process goes on, the chronic epididymo-orchitis keeps 
on its course, and then we find a much enlarged epididymis, which 
is hard, knobby, and irregular. In some cases the lesion in the 
epididymis preponderates, and then that appendage is very large 
indeed, and the as yet uninvaded testis forms but a small portion 
of the morbid tumor. Then, again, the growth in the testis keeps 
pace with the process in the epididymis, and a large mass is pro- 
duced. 

Hydrocele is observed in about one-third of the cases of tubercle 
of the testis. In some exceptional cases tuberculosis of the testis 
(one or both) presents the same clinical picture as is offered by 
syphilitic sarcocele. By slow degrees, with some or little pain, 
the testis and epididymis enlarge and form an ovoid or pear- 
shaped tumor, which has a smooth surface and hard, firm consist- 
ence, and which may be mistaken for syphilitic sarcocele or cystic 
sarcoma of the testis. These tubercular testes may be as large as 
a good-sized pear or a large fist. They may remain intact for a 
long period, and they may become the seat of abscess and fistula 
and of fungoid development. In some of these cases I have 
observed small and large rounded nodulations on the surface of 
the testis. It is always difficult and often impossible in this form 
of tuberculosis of the testis to discover the epididymis or to settle 



180 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

in one's mind how much it contributes to the general swelling, 
since the parts are so intimately merged together. 

The life-history of patients suffering from tubercle of the testis 
is that of tuberculosis in general. In some cases the patients live 
for years after the extirpation of the organ or organs ; in others 
death follows sooner or later from extension of the disease to vital 
organs. 

Besides the strikingly well-marked features presented by the 
affected testis, there is, in most cases, evidence of prostatic involve- 
ment in the shape of enlargement and large and small nodulations, 
and perhaps of irregular infiltrations in the ampullated ends of the 
vasa deferentia and of the seminal vesicles, which may be ascer- 
tained by digital examination in the rectum. 

In many cases of tubercular testis the scrotal part of the vas 
deferens is more or less attacked. There may be slight thicken- 
ing and enlargement, circumscribed or diffuse, or the tube may be 
so nodulated that it feels like a string of beads of various sizes. 
A testis attacked by tuberculosis soon ceases to possess the sper- 
matogenic function. 

In all probability, tubercular invasion of the epididymis and 
testis destroys the function of the gland much sooner and more 
frequently than we have heretofore thought. It must be remem- 
bered that even in mild and indolent cases the development of 
toxins occurs in association with the morbid tissue-changes, and 
these poisons permeate the structures of the testis and destroy the 
delicate arrangement by which the spermatogenic function is per- 
formed. In very acute cases the extensive swelling and hyper- 
emia are, undoubtedly, largely due to the diffusion of the poisons 
through the whole gland. It is fair to assume that this condition 
destroys the function of the testis at once. Then, in addition to 
this diffusible poison, the cell-changes so destroy the integrity of 
the gland that it soon becomes useless as a producer of sperma- 
tozoa. 

Involvement of the two glands carries with it sterility. The 
foregoing considerations show what a widely deleterious influence 
tuberculosis exerts upon the sexual function. 



AZO 6 SPERM A TISM. 181 

Treatment. The most important point in the management of 
cases of tuberculous testes, and in which other organs and tissues 
(lungs, kidney, bladder, prostate, vesicle, etc.) are attacked, is the 
removal of the patient to a suitable climate which is high, dry, 
and sunshiny — the Adirondacks, Southern California, and Colo- 
rado. In all cases it must be remembered that climate is the chief 
curative factor, and that the action of drugs is only secondary. 
Benefit, however, may result from the use of cod-liver oil, the 
hypophosphites, creosote, iodide of iron, and tonics, all of which 
should be judiciously employed. The adoption of surgical meas- 
ures depends wholly upon the extent and seat of the tubercular 
lesion. 

If there are indurated masses in the epididymis or in the testes 
these points should be incised, thoroughly scraped, and packed 
with iodoform gauze. 

If there are sinuses leading into the epididymis or testes they 
should be enlarged, scraped, and packed with absorbent gauze or 
iodoform ointment. 

When the entire testis is extensively involved and broken down 
it is necessary to resort to castration ; but in these cases the neces- 
sity of climatic change should be forcibly impressed on the patient. 

TUBERCULOSIS OF THE PROSTATE. 

The prostate is involved in the majority of cases of tuberculosis 
of the genito-urinary tract. Its development may be primary or 
secondary to infecting foci in adjacent or remote parts. It is 
mostly observed at puberty and in early life. 

Tuberculosis of the prostate may cause azoospermatism by the 
obliteration of the ejaculatory ducts. 

The course of tuberculosis of the prostate may be acute, sub- 
acute, or chronic. 

In the majority of cases the disease begins in the urethra, but 
it is also found in the substance of the gland and on its periphery, 
particularly near the rectum. 

In cases of urethral involvement the symptoms are complained 



182 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

of quite early. The most prominent symptom is pain, particularly 
on urination, which may be very urgent, and it may be either con- 
tinuous or intermittent. Invasion of the prostate is usually fol- 
lowed quite promptly by extension to the bladder, with its cus- 
tomary group of symptoms. 

In cases of prostatic tuberculosis there is usually a more or less 
profuse mucopurulent discharge, which may escape spontaneously 
or on defecation. When the tuberculous nodules are seated in the 
parenchyma of the prostate they may not give rise to pronounced 
symptoms for some time. This is particularly the case when the 
course is very chronic. When the tuberculous nodules are seated 
toward the periphery of the organ they may occasion few, if any, 
symptoms, but when they are very superficially seated, particularly 
near the rectum, they may cause pain and uneasiness in those parts. 

On rectal examination the finger-tip may not encounter any 
abnormality when the urethral part of the prostate is attacked. 
When the nodules are seated in the parenchyma of the organ and 
they have become quite large, or when several have coalesced and 
project on the surface, their presence may be determined by pal- 
pation with the finger in the rectum. 

The diagnosis of prostatic tuberculosis may be made by exam- 
ination of the morbid secretion or of the urine. But in many 
cases such examinations fail to reveal the bacillus tuberculosis 
until digital pressure has been brought to bear on the gland and 
on the urethral canal. 

Treatment. Tuberculosis involving the urethral canal may 
be benefited by prostatic and bladder irrigations of warm solutions 
of bichloride of mercury (1 : 3000 or 1 : 8000). In the event of 
this treatment causing pain and urethral irritation it will be neces- 
sary to discontinue it. In some cases iodoform and sweet oil (10 
per cent.), in the form of injections, have seemed of benefit in 
cases of ulceration of the urethra. 

Tubercular abscesses of the prostate near the rectum may be 
reached by a crescentic incision made an inch in front of the anus 
between the prostate and the rectum ; they are then incised and 
packed with iodoform gauze. 



AZOOSPERMATISM. 183 

Change of climate (see section on Tuberculosis of the Testis, 
p. 181) is the main indication in these cases, which are usually 
those of more or less extensive distribution of the tubercular 
process. 

TUBERCULOSIS OF THE SEMINAL VESICLES. 

This condition is rarely, if ever, of primary development, but 
is usually found synchronously with tubercular prostatitis and 
cystitis. It is a disease of early life, and very frequently coexists 
with tuberculous infiltrations of other organs more or less remote. 

By rectal examination with the finger a nodular swelling is 
found continuous with and just above the prostate. The tissues 
can be felt to be much infiltrated and quite boggy. 

In many cases the ampullations of the vasa deferentia are in- 
volved, and they feel like brawny, insensitive swellings. 

When the seminal vesicles are involved by the tuberculous 
process their respective ducts are generally involved simultane- 
ously, and from these foci the morbid process may extend and 
attack the ejaculatory ducts. 

Whenever the seminal vesicles and the ampullae are the seat of 
tuberculosis, a mucopurulent discharge, mixed with grumous 
masses and sometimes with blood, forms within them, which when 
the ducts remain patulous may escape through the urethra. 

When these seminal sacs and the ampullations are the seat of 
tuberculosis, sexual erethism may be complained of at first, but 
later on impotence is observed. When in these conditions the 
morbid tissue products become mixed with the normal secretions 
of the parts, the spermatozoa are destroyed. It is very probable 
that when tuberculosis attacks the vasa deferentia the spermatozoa 
are killed as they pass upward from the testes. 

Treatment. The remarks already made on the necessity of 
climatic treatment (see page 181) hold good in cases of tubercu- 
lous spermatocystitis. Care as to hygiene, diet, and suitable 
therapeutic measures should also be exercised. 

Such is the extent of tubercular infection in most cases that 



184 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

surgical operations on the seminal vesicles alone are not indicated. 
Abscess of these parts may be reached by a crescentic incision 
about an inch in front of the anus and carried down between the 
prostate and vesicles and the rectum. The parts are, after careful 
irrigation, packed with iodoform gauze, which is held in place 
by a retentive dressing. Excision of the vesicles may be accom- 
plished by means of Kraske's or ZuckerkandPs incision. 

ATROPHY OF THE TESTIS. 

As has been shown in some of the foregoing sections, atrophy 
of the testis is very common, and it is due to a great variety of 
causes. 

In the young subject the gland may become dwarfed by reason 
of abnormal retention and of malposition or ectopia. In old sub- 
jects, senile changes begin earlier in the testis than in other parts 
of the body, and the organ may be reduced to a mere mass of 
fibrous tissue without any trace of glandular structure. 

Arthaud 1 has shown that in the testes of men beyond fifty years 
of age atrophic changes usually become established. The essen- 
tial lesion is a peritubular sclerosis, which leads to the gradual 
disappearance of the epithelium. As a result the seminiferous 
tubules are destroyed, and sometimes cysts are developed. The 
underlying causes are vascular interference and insufficient nutri- 
tion of the glands. 

Desnos 2 has further shown that in old men the periepididymal 
veins become much dilated, and that this process slowly goes on 
until the veins of the parenchyma of the epididymis are involved. 
The result of this pressure is the mechanical obliteration of the 
efferent seminal vessels and the transformation of these structures 
into dense, fibrous tissue. Desnos further claims that hydrocele, 
which is not uncommonly found in old men, causes by its com- 
pression atrophy of the testis. 

1 Etude but le testicule senile. These de Paris, 1885. 

2 Recherches sur l'appareil genital des Vieillards. Annales des Mai. des Org. 
Gen.-urin., 1886, Tome iv. pp. 72 et seq. 



AZO OSPERMA TISM. 185 

By way of recapitulation we may briefly refer to the following 
facts, and also call attention to several rather infrequent causes 
of atrophy of the testis. As a complication in the course of a 
number of infectious diseases the testis is not infrequently in- 
volved, and the outcome is very often atrophy or structural degen- 
eration. 

Gonorrhoea may, in rather exceptional cases, end in testicular 
atrophy, but its danger to the sexual capacity resides in its ten- 
dency to occlude the spermatic tubes. 

Syphilis is a potent and frequent factor in the production of 
atrophy of the testis and of the epididymis, and occupies a 
prominent place in the category of causes of sexual impairment 
and sterility. 

Hydrocele and hematocele may lead to moderate and temporary 
or permanent azoospermatism by reason of the structural changes 
which they produce in the testis and epididymis. 

It is doubtful whether varicocele produces true atrophy of the 
testis, except in very rare instances. 

In a certain number of cases of elephantiasis of the scrotum 
true atrophy of the testis has been observed. In some forms of 
hemiplegia, general paresis, and in some cases of traumatism of 
the skull, brain, cerebellum, medulla oblongata, and spinal cord, 
wasting of the testes is observed. In these cases the spinal sexual 
centre is so affected that its function is destroyed. The long-con- 
tinued use of iodide and bromide of potassium and belladonna 
has been stated to be the cause of atrophy of the testes. 



CHAPTER XV. 

AZOOSPERMATISM DUE TO ABNORMAL CONDITIONS 
OF THE SEMEN. 

As has already been shown in a previous chapter, in healthy 
men each ejaculation of semen, after some clays of continence, 
contains many millions of spermatozoa. There is, as has already 
been stated, much variation in the structure and vital activity of 
these bodies in different men. In the strong and vigorous they 
are large and long and very lively, and from this standard (see 
Fig. 19) they decrease both in size and in vital energy. In all 
probability there are in man, as in animals, periods in which the 
process of spermatogenesis is less active than at other times, and 
that intervals of rest may actually occur. In some men this func- 
tion is most active and continuous, and as a result the sexual desire 
is very keen. In others it is more sluggish, and has intervals of 
repose, and the sexual activity of the man is less pronounced ; 
while in still others the production of spermatozoa is very slow, 
halting, and feeble, and these vitalized bodies are much less de- 
veloped and active than they are in very vigorous men. We thus 
find that the development of spermatozoa represents a sliding scale 
from full, vigorous structures down to puny and almost inanimate 
bodies. 

THE EFFECTS OF REPEATED AND EXCESSIVE 

corros. 

The observation of Liegois, already quoted (see p. 68), which 
has the support of many other investigators, goes to show that 
after excesses in coitus there is for a time absence of spermatozoa 
from the seminal fluid. Recovery from this condition is speedy 
in some men and more or less delayed in others. In Liegois' 
case it was found by the microscope that after abstinence from 



AZO OSPERMA TISM. 187 

coitus for three weeks large numbers of these bodies were 
found. The most extended series of observations as to the 
effect of coitus upon the size and number of spermatozoa is that 
contained in the case reported by Casper/ which is very instruc- 
tive. Casper says : " A vigorous naturalist, sixty years of age, 
a married man, and father of a large family, and accustomed to 
the use of the microscope, whom I had interested in this question, 
examined with me for some time continuously his own semen 
after coitus. Here we found the greatest variations, which were 
accurately noted by both of us together. After coitus on the 
third day, reckoning from the last performance of the act, there 
was a large number of very small spermatozoa ; after renewed 
coitus on the fourth day, few and small ; after a pause of only 
two days, none ; after a pause of only one day there was only a 
watery sperma, in which no zoosperms were found. At another 
time, on the fifth day after the last coitus, the zoosperms were 
very numerous ; another time, after a pause of six days, they 
were few, but large in size ; four months after the last examina- 
tion, and seventy-two hours after the last act, the zoosperms were 
comparatively very small, and at another time, on the third day 
after the last act, they were innumerable. Immediately after 
coitus, and before emptying the bladder, the urethra was twice 
examined. Twenty-four hours after the last act a drop passed out 
of the urethra exhibited numerous small zoosperms ; at another 
time, after a three days' interval, there was not a single zoosperm." 
In the event of repeated coitus it is probable that the supply 
of spermatozoa is exhausted after the first few acts, and that 
thereafter in cases of excess the secretion comes from the seminal 
vesicles (perhaps a little from the prostate) and from Cowper's 
and the muciparous glands of the urethra. In the observation 
reported by Guelliot, 2 in which a man had coitus eleven times in 
one afternoon, it is noted that after the eighth encounter the secre- 
tion consisted only of turbid serosity (serosite louche). 



1 Forensic Medicine. Sydenham Society's edition, 1864, p. 292. 

2 Des Vesicnles Seminales, etc., pp. 214 et seq. 



188 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

These careful observations have been fully confirmed by experi- 
ments upon animals by means of electrical stimulation of the spinal 
centre. It is reasonable to suppose from what has thus far been 
presented that the semen of men who are addicted to long-con- 
tinued sexual excesses is, as a rule, unfertile, and that the power 
of fecundation (potent id gcnerandi) can only be repaired by con- 
tinence and as the result of the restoration of vigorous health. 

INFLUENCE OF THE PROSTATIC SECRETION. 

Any morbid condition which interferes with the integrity of 
the prostatic secretion is liable to so alter the condition of the 
semen that its fructifying elements may become unfertile. These 
morbid conditions are mainly chronic posterior urethritis and 
chronic inflammation of the prostatic tubules, and in the same 
category may be included the plugging of the prostatic ducts 
with concretions, destruction, more or less great, of the gland fol- 
lowing gonorrheal abscesses, and the late developing small cell, 
submucous infiltration resulting from chronic posterior urethritis, 
which so scleroses the tissues that the ducts cannot perform their 
function. As causes of these morbid conditions, besides gonor- 
rhoea, may be mentioned masturbation, excesses, and unsatisfied 
sexual desire, which cause congestion of the prostatic tubules, 
with the consequent loss or impairment of their secretory func- 
tion. Since all of these morbid conditions may lead to sexual 
neurasthenia and impotence, a further impairment of the integrity 
of the semen may arise in the exhausted condition of the system, 
which for a time may hold in abeyance the process of spermato- 
genesis. I have myself made many observations upon this class 
of cases, and have found that the spermatozoa are very small and 
dwarfed in size, scanty in numbers, and very feeble and languid 
in their movements. When, however, the integrity of the func- 
tion of the prostate is restored, and with it the establishment of a 
renewal of health, the conditions of the zoosperms gradually change 
until they assume normal proportions and become vigorously 
active. 



AZOOSPERMATISM. 189 

My observations and studies have convinced me that to the nor- 
mal chemical composition of the prostatic fluid, consisting largely 
of phosphates of lime and soda, the healthy condition of the semen 
is largely due. 

In the chronic subacute prostatitis which follows excessive 
masturbation and sexual excesses it is not uncommon to find the 
granular phosphates in superabundant quantity suspended in a 
rather thick gelatinous mucus. Now, in the semen of many of 
these cases I have observed that the zoosperms were little, frail 
bodies, having scarcely any activity. The pertinent question, 
therefore, suggests itself whether this great excess of alkaline 
admixture has a devitalizing effect on the spermatozoa ? Several 
husbands whom I have known to be thus affected were childless, 
although they had vigorous and florid wives. 

Absence or scantiness of the prostatic secretion in the ejaculate 
may lead to sterility (impotentia generandi) by reason of the 
non-occurrence of the normal fluidity of the secretion. We have 
already seen that the dense, lumpy, viscid secretions of the am- 
pullations of the vasa deferentia and of the seminal vesicles are 
partially liquefied by the admixture of the alkaline prostatic secre- 
tion, and that then the spermatozoa have nothing to impede their 
vital activity or to prevent their invasion of the genital canals of 
the female. When this partial liquefaction does not occur the 
zoosperms are, so to speak, held prisoners, and they cannot go on 
their way to the fertilization of the female ovule. I have seen 
several cases in which men's ejaculate has been a little grayish, 
lumpy mass, of considerable consistence, about the size of two 
peas, in which, even when very recently voided, the spermatozoa 
were thin, puny, and almost lifeless. In these cases some of the 
men were in bad health, and in others there was chronic prostatic 
involvement. 

Beigel 1 has reported a case in which this variety of semen was 
present, and in which fecundation occurred as a result of throwing 
a small amount of warm water into the vagina after coitus. If 

1 Krankheiten des "Weiblichen Geschlechts, etc. Erlangen, 1874, B. ii. p. 791. 



190 SEXUAL DISORD ERS OF THE MALE AND FEMALE. 

this measure is to be of benefit in the melting-down of the sem- 
inal mass, it seems to me that the most rational solvent would be 
a very dilute, watery solution of phosphate of lime and soda 
(1 : 100 or 1: 200) slightly warmed. In my cases benefit followed 
topical treatment of the genital tract. 

Pus-admixture. 

In acute gonorrhoea of the urethra the seminal fluid is more or 
less contaminated by pus-admixture, and the spermatozoa are 
found to be lifeless or capable of very little motion, as I have 
seen in numerous microscopic examinations. It is very probable 
that gonorrhoea or its toxins exert a deleterious or even deadly 
influence on these frail bodies. Terrillon 1 has clearly shown that 
in bilateral gonorrhoeal epididymitis the semen is mixed with pus 
and that spermatozoa are absent. His observations go to show 
that as long as pus is produced in the epididymis, even in small 
quantity, its effect is so lethal to spermatozoa that the semen 
remains unfertile. In all probability healthy spermatozoa are 
killed in the female genitals by pus or its poisons. In some cases 
failure of impregnation undoubtedly is due to the presence of 
the thick, viscid plug of mucus or muco-pus in the uterine neck, 
which, by its density, offers a barrier to the spermatic invasion. 

The extent of the influence of acute or chronic gonorrhoeal 
seminal vesiculitis and gonorrhoeal inflammation of the defer- 
ential ampullations is really not Avell known, and most of the 
reported cases of this morbid condition are fragmentary and unsat- 
isfactory. Just after recovery from acute gonorrhoeal seminal 
vesiculitis it is positively known, as I can affirm from observation, 
that the semen is a thin, turbid, yellowish secretion, more copious 
than in health, containing few, if any, spermatozoa, and more or 
less pus. Now, in these cases it is probable that the spermatozoa 
have been killed by gonococci or toxins. How long this condition 
lasts we are unable to say, but it is fair to assume that healthy 
spermatozoa can only live in these secretions when they are nor- 

1 Op. cit., p. 439. 



AZOOSPERMATISM. 191 

mal and free from toxic admixture. In chronic seminal vesiculitis, 
though the pus may be less in quantity and the toxins less viru- 
lent, such is the effect of their presence that the nutritive media 
of the spermatozoa (the secretions of the ampullations and the 
seminal vesicles) are so altered that these organisms are either 
dwarfed or killed outright. 

Whether a purulent inflammation of the ejaculatory ducts can 
so alter the composition of the semen as to render it unfertile we 
are not able to say, but it is obvious that gonorrheal pus-admix- 
ture is a dangerous factor, even when present in small quantity. 

When we reflect upon the foregoing considerations the convic- 
tion forces itself on our minds that pus in the deep sexual parts 
may have much to do in causing temporary or permanent azoosper- 
matism. 

Blood-admixture. Bloody Ejaculations. 

The semen may become mixed or streaked with blood, owing 
to a morbid condition of some part of the sexual tract. It is 
difficult to determine how far blood-admixture tends to induce or 
produce azoospermatism. To settle the question it is necessary to 
understand the nature of the processes which lead to or cause the 
escape of the blood, and to ascertain whether this fluid can exert 
a morbid effect on the zoosperms. Experience and study seem to 
show quite clearly that a small amount of blood mixed with the 
semen does not destroy its fecundating property. Large amounts, 
however, may so dilute this fluid that its germinative faculty is 
lost, probably through dilution. In tuberculosis of the testis the 
semen may become thoroughly mixed with blood, and may then 
resemble red currant jelly (rose semen). Such semen is, as a rule, 
unfertile, as a result of toxin-action, and the blood-admixture has 
probably little effect on its integrity. 

In acute and chronic gonorrheal inflammation of the seminal 
vesicles and deferential ampullations the escape of blood is not 
uncommon. But in these cases there is an underlying virulent 
process, which may by its poisons kill the spermatozoa. Bloody 



192 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

semen in these conditions may have a fresh red color or it may 
have a decided rusty tint. The intermixture of blood and semen 
is in these cases usually intimate and well blended. It is very 
probable, as claimed by Jam in, 1 that a passive congestion of the 
seminal vesicles (and, I would add, the ampullations) may result, 
without gonorrhoeal infection, from excessive coitus, masturbation, 
and perhaps even from prolonged continence, and that this con- 
gestion may give rise to little hemorrhages and blood-admixture. 
When this occurs the semen has the rusty color already mentioned. 
We have no knowledge as to whether such semen is fertile. 

In cases of gonorrhoea involving the ejaculatory ducts small 
hemorrhages in and around these tubes have been found, on post- 
mortem examination, to have occurred. It is fair, therefore, to 
assume that in some cases the semen may become streaked with 
blood in its passage through these canals. In its acute declining 
stage and in chronic gonorrhoeal posterior urethritis more or less 
copious hemorrhages may occur in coitus or in pollutions, and as 
a result the semen is streaked with bright-red blood. In like 
manner in acute or chronic gonorrhoea of the bulb of the urethra 
hemorrhages sometimes occur in coitus or pollutions, and in some 
instances they are very copious. I have seven several men in 
whom the flow of blood was quite severe, and who when in coitus 
thought it was due to incipient menstruation in the female. 

In all probability blood itself is not noxious to the vitality of 
the spermatozoa, but the gonorrhoeal process is distinctly so. In 
large quantity, however, the blood may so dilute the seminal fluid 
that the fecundating power of the zoosperms is lost. 

It is very rare that lesions seated in the course of the pendu- 
lous urethra cause enough bleeding to tinge the semen in transitu. 

THE INFLUENCE OF GENERAL MORBID CONDITIONS. 

In sexual neurasthenia it is not uncommon to find azoosperma- 
tism, which may be due to the general malnutrition of the patient 

1 Considerations Pathogeniques sur l'Hemospermie d'Origine non-inflamma- 
toire. Annales des Mai. des Org. Gen.-urin., 1891, pp. 765 et seq. 



AZOOSPERMATISM. 193 

or to the local lesion which is the main cause of the nervous state. 
In general, in this class of cases there is some form of chronic 
prostatic affection or disease of the ampullations and of the sem- 
inal vesicles which leads to an unfertile condition of the semen. 

It is no longer contended that all persons suffering from tuber- 
culosis are azoospermatous, since spermatozoa have been found in 
the deep sexual parts of many men who died of phthisis. When 
the testes or epididymes are invaded by tubercular inflammation 
the spermatozoa are probably killed by the toxins developed. In 
several instances I have seen such viscidity and lumpiness of the 
semen of consumptive men that I have been certain that the puny 
and sometimes fatty degenerated spermatozoa were incapable of 
impregnation. I have seen several instances in which such men 
have cohabited for long periods with perfectly healthy women who 
did not become pregnant, although they had taken absolutely no 
measures to avoid that condition. 

In all probability when phthisis causes azoospermatism it is 
by its local lesions in the testes and epididymes, in the ampulla- 
tions and seminal vesicles, and in the prostate or by its general 
adynamic effect, which dwarfs the production of healthy zoosperms 
and prevents the formation of a mucus of proper nutritive quality 
and of normal specific gravity. The influence of syphilis on 
spermatogenesis has already been considered. (See page 162 et 
seq.) It may be added, however, that perhaps in the early stage, 
when the poison is very active and abundant, it may interfere 
with the delicate process of zoosperm development. It is not 
uncommon, however, to see men in whom syphilis is yet active 
impregnate healthy women, nor is it rare to see recently syphilitic 
women become pregnant by healthy or syphilitic men. 

We have no scientific evidence as to the influence of general 
infective processes upon the formation of the semen. It is prob- 
able that during the activity of the disease, and perhaps for some 
time afterward, spermatogenesis ceases. 

Xo general statement can be made as to the effect of old age 
upon the production of semen, since there is so much variation 
in the sexual activity and capacity of different men. In some 

13 



194 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

instances fertile semen is present in men of sixty-five, seventy- 
five, and even beyond ninety years. In general, however, a 
gradual or rapid decline in the productivity of the testes begins 
at or before the sixtieth year. In some men, however, the sper- 
matogenic function is lost much earlier in life. 

Any cause, therefore, which deranges the structure of the testis 
impairs its function, and as a result spermatozoa may not be pro- 
duced, and the seminal cells may be present in, or they may be 
absent from, the semen. 

In Plate VII. azoospermatous semen from a patient who suf- 
fered from chronic gonorrhoeal epididymo-orchitis is depicted in 
which seminal cells and granular phosphates are present. 

Watery Semen and Colloid Semen. 

Though special mention is made of these forms of semen, they 
are in reality only symptomatic of some chronic affection of the 
ampullations of the seminal vesicles, of the prostate, or of the 
testes. 

Watery semen is usually of a slightly yellowish, turbid color, 
and consists of a thin mucus in which are suspended living or 
dead spermatozoa in small quantity, with perhaps some pus-cells 
and granular phosphates. In some cases it has been observed 
that watery semen is very copious, since as much as one or two 
tablespoonfuls, or even two ounces, have been discharged at one 
ejaculation — a condition which is called polyspermia. In such 
cases impregnation can scarcely occur, since the spermatozoa 
cannot obtain a hold on the vaginal mucous membrane, but are 
carried away in the flood. 

Watery semen is the direct result of morbid changes in the 
ampullations and in the seminal vesicles, which so impair the 
functions of the muciparous glands that a very diluted secretion 
is produced instead of the normal viscid and heavy mucus. Fol- 
lowing double gonorrhoeal epididymitis, watery semen may be 
ejaculated for varying periods of time. 

A colloid condition of the semen is, as a rule, observed in cases 



PLATE VII 




Seminal Cells and Granular Phosphates from 
Azoospermatous Semen. 



AZOOSPERMATISM. 195 

in which the prostatic secretion is not thrown into the nrethra at 
the time of emission. It is, therefore, the direct outcome of chronic 
morbid processes in the prostate gland. Normally, as we have 
seen (page 69), the secretion of the ampullations and the seminal 
vesicles is viscid and lumpy, as shown in Fig. 20, in which the 
round, oval, and irregular, small, large, and very large masses of 
glairy and glassy mucus are shown. This lumpy condition is 
rapidly liquefied and broken up when the prostatic fluid is mixed 
in the prostatic urethra with the secretions from behind — e. g., 
from the ampullations and the seminal vesicles. 

In this colloid condition of the semen the movements of the 
spermatozoa, even if healthy, are so hindered that they cannot 
bring about their irruption into the uterine cavity, hence the semen 
is, by reason of a mechanical cause, unfertile. With the cure of 
the prostatic infirmity and the re-establishment of the secretory 
function of that gland the colloid condition of the semen ceases, 
and it again becomes a fertile fluid. In the semen of persons 
addicted to the opium-habit spermatozoa are either absent or 
poorly developed. 

Diminished Quantity of Semen. 

When the spermatic ejaculate of a man is very small he is said 
to be suffering from the condition uneuphoniously called oligo- 
spermia. This condition is found in feeble and old men, in con- 
sumptives, or persons who have committed sexual excesses, and, 
exceptionally, in chronic, seminal-vesicular, and deferential dis- 
ease. In some men, even in those seemingly very healthy, the 
secretion of semen is normally very small, even to the amount of 
a few drops ; in others the quantity is larger, and so on the scale 
rises until the normal free ejaculation is present. 

Prognosis. In order to give a patient an intelligent and honest 
forecast as to his sexual future in cases of disease or imperfect 
semen, it is absolutely necessary to get a full and accurate history 
of his sexual habits, and to clearly ascertain the morbid condition 
underlying his infirmity. In cases of sexual excess of any kind 



196 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

the prognosis depends entirely upon the docility and future good 
conduct of the patient. When urethral, prostatic, seminal-ves- 
icular, and ampullation morbid conditions are the direct causes, 
the future of the case intimately depends upon the accuracy of 
the diagnosis and the efficiency of the treatment. 

In tuberculosis we cannot hold out bright hopes of sexual resto- 
ration ; but in neurasthenia, in general debility, and in syphilis it 
is fair to assume that appropriate treatment, together with good 
hygiene in its broadest sense, will bring about improvement, and 
even cure. In all cases in which gonorrhoea is an active factor 
the outcome depends on the ability of the surgeon to remove the 
morbid process. 

Treatment. It is unnecessary here to do other than refer to 
the therapeutic sections of the chapters on diseases of the testes, 
on chronic posterior urethritis, prostatitis, and seminal vesiculitis. 



CHAPTER XVI. 

ASPERMATISM. 

The term asperinatisin is applied to that condition in which 
the power of normal coitus exists, but in which the ejaculation of 
semen does not occur either in that act or during sexual excite- 
ment. In such cases the final period of the sexual act is absent. 
Patients thus afflicted say that the contractions of the perineal 
muscles which complete ejaculation are absent. The term is fur- 
ther used to embrace cases in which there is a deficiency in the 
quantity of semen ejaculated, and also those cases in which there 
is impeded, defective, or imperfect ejaculation. 

This condition is much rarer than azoospermatism, and it depends 
on lesions seated between the deferential ampullations and the 
seminal vesicles, and the meatus urinarius or the preputial orifice. 

The essential cause of aspermatism is the stenosis, or blocking 
up, or destruction of some part of the sexual tract to such an ex- 
tent that in the rhythmical movements of ejaculation the seminal 
fluid is either directed from or dammed back in the course of the 
urethra. The impediment may occur in the seminal vesicles, the 
deferential ampullations, the ejaculatory ducts, the prostate gland, 
the urethral canal, at the meatus urinarius, or the preputial orifice. 

Aspermatism may be either permanent and absolute or tempo- 
rary and relative. 

LESIONS OF THE SEMINAL VESICLES AND 
DEFERENTIAL AMPULLATIONS. 

Aspermatism due to fistulous tracts passing from the seminal 
vesicles to the rectum or bladder is so rare that such a case would 
be looked upon as a curiosity. Several such cases are on record 
in which the fistulse resulted from bladder or lithotomy opera- 



198 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

tions. In these cases the semen was ejaculated into the rectum. 
It is possible that sympexia may become lodged in the orifice of 
the seminal vesicle or in that of the deferential ampullations ; in 
general, however, the plugging up occurs in the ejaculatory ducts. 

LESIONS OF THE EJACULATORY DUCTS. 

A variety of morbid conditions may occur in and around the 
ejaculatory ducts which may result in aspermatism. The plug- 
ging up of these minute canals by sympexia is of rather rare 
occurrence. A most striking instance of this accident is presented 
by ReliquetV case. It was that of a man, aged thirty-five, who 
in coitus was seized with a severe pain in the deep urethra which 
radiated to the anus and perineum. Afterward defecation and 
urination became painful, and coitus was so agonizing that it was 
not indulged in. By rectal examination the left seminal vesicle 
was found swollen. The man was examined by means of a litho- 
trite, and after withdrawal the patient experienced severe pain in 
the penis, which was followed by the discharge from the urethra 
of a large quantity of sympexia. After this relief the perform- 
ance of the sexual function was perfect. 

It is very probable that in this and in similar cases the great 
distention of one ejaculatory duct blocks the other one up very 
effectually, as these canals lie so close together in the prostate. 

Cases have been reported in which, on post-mortem examination, 
the ejaculatory ducts have been found to be plugged by concretions 
as large as a pea or a cherry, which were composed of carbonate 
and phosphate of lime, and mucus and spermatozoa. Chronic 
gonorrhoea has been found to produce a stenosing condition of the 
ejaculatory ducts, chiefly by its round-cell infiltration of the sub- 
mucous connective tissue of the verumontanum, which it attacks 
more severely than other portions of the posterior urethra. Round- 
cell infiltration around the ducts producing stenosis has been found 
in the dead subject. 

Dense fibrous bands upon and behind the verumontanum have 

1 Picard : Traits des Maladies de la Prostate. Paris, 1877, p. 129. 



AS PER MA TISM. 199 

been seen to so compress or distort the ejaculatory dncts that either 
stenosis has been produced, or a deviation in the course of the 
ducts or of their orifices has resulted. In the former event the 
semen was dammed backward ; in the latter it was in coitus 
thrown backward into the bladder. 

Arch-like bands of fibrous tissue have been found seated saddle- 
like across the summit of the verumontanum, and as a consequence 
one or both ducts were obliterated. Gonorrhoea may cause abscess- 
formation in some or many of the prostatic tubules, which may 
result in such scar-tissue development that the ejaculatory ducts 
are destroyed. 

In some cases of chronic gonorrhoea the involvement of the 
tubules has ended in cystic degeneration, which was produced by 
sclerosis of the tissues and obliteration of the ducts. 

Cases are on record in which traumatism of the prostate and 
verumontanum, resulting from the passage of, or retention of, 
sounds and catheters, has been so severe that the ejaculatory 
ducts have either been compressed or the direction of their orifices 
has been thrown so much out of place that they have looked back- 
ward to the bladder. This retroversion of the orifices may be 
partial and only cause them to look upward, or it may be complete, 
in which event the discharge of semen occurs directly backward. 

Displacement of the ducts and of the prostate has been known 
to follow abscesses of and injury of the perineum (from falls, 
blows, and infectious processes), which caused a dense fibrous 
cicatricial mass to draw that gland downward and to much distort 
the ano-perineal and rectal regions. 

In tuberculous inflammation of the prostate the ejaculatory 
ducts may be compressed or destroyed. 

In old men these canals may, when the prostate becomes hyper- 
trophied, either be narrowed or entirely stenosed. 

Calculi and concretions in the prostate may cause compression 
or stenosis of the ejaculatory ducts, and aspermatism may result. 
It is probable that when many prostatic tubules and their ducts 
are plugged up by lime, salts, mucus, and amyloid bodies, inju- 
rious compression may be exerted upon the ducts. 



200 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

Abscess of the prostate with its (in favorable cases) subsequent 
cicatricial development and resulting contraction may utterly oblit- 
erate these little canals. A very interesting case was reported 
many years ago by Dugas, 1 which is worthy of a brief summary. 
A man, aged twenty-six years, was attacked after a long horse- 
back ride with pain and tenesmus in urination and shooting 
twinges in the rectum. He had fever and was delirious. The 
prostate was found, upon rectal examination, to be very large and 
painful, and an abscess was suspected. The operator, with his 
left index finger in the rectum, firmly supported the prostate, 
while with the other hand he introduced a sound into the urethra, 
the tip of which, on abutting against the abscess, ruptured it and 
a quantity of pus soon escaped. Two months after this the man 
complained of an acute pain during ejaculation, and stated that 
his emission was only half as copious as it was before his sick- 
ness. In all probability one of the ejaculatory ducts of this 
patient was obliterated, for it was noted after healing had taken 
place that the prostate had lost one-third of its volume. 

Diminution in size and distortion of the shape of the organ are 
generally found after abscess of the prostate. 

It is not uncommon for abscess of the prostate to open into the 
rectum, into which the urine and semen are for long or short 
periods discharged. In this event temporary or permanent 
aspermatism may result. This may occur also when the ab- 
scess opens into the bladder, the inguinal region, and the sciatic 
notch. 

Perineal fistulas may result from abscess of the prostate, and in 
this event if the ejaculatory ducts be not obliterated the emission 
will probably pass through the false passages and ooze out at the 
perineum. 

Permanent aspermatism may result from injury of the ejacula- 
tory ducts in the operations of lateral or bilateral lithotomy. 
There are a number of well-reported cases on record, and two 
have been added by Horwitz. 2 

1 These de Montpellier. 1832. 

2 Journal of the American Medical Association, April 8, 1893. 



ASPERMATISM. 201 

Iu the rare event of congenital absence or atrophy of the pros- 
tate semen cannot reach the urethra, for the reason that there are 
no ejaculatory ducts to transmit it. 

STRICTURE OF THE URETHRA AND URETHRAL 

CALCULI. 

Stricture of the urethra is not uncommonly the cause of asper- 
matism, and also of impeded or imperfect ejaculation. It is to 
be remembered that in normal coitus the semen having been 
thrown into the bulbous urethra, the intrinsic and extrinsic 
muscles of this segment of the canal then forcibly contract and 
throw the ejaculate toward the meatus. (See page 59.) For the 
proper performance of this part of ejaculation it is necessary that 
the integrity of the urethra outside of the triangular ligament 
should be retained. Whenever, therefore, any considerable con- 
traction of the bulbous urethra is produced (and it is generally 
caused by gonorrhoea) the ejaculatory act will be lame and halt- 
ing at this part. Thus it is not uncommon for men having soft 
strictures, down to 15 or 20 of the French scale, to complain of 
disability and a sense of some impediment being present at the 
end of coitus in the bulbar region. In some of these cases the 
ejaculation is weak and prolonged ; in others it is more or less 
incomplete, and as the penis becomes flaccid the emission slowly 
dribbles from the meatus. 

In the case of a tight stricture at the bulb there may be no 
emission at all in coitus, but a dribbling discharge may occur some 
time after the completion of the act. In this event the semen is 
dammed backward in the membranous urethra and in the ante- 
rior portions of the prostatic urethra, and it slowly flows forward 
after a short or quite long interval. Men thus afflicted sometimes 
complain of pain, due to slight spasm of the compressor urethrse 
muscle and to the abnormal distention of the canal. In other 
cases a sense of fulness is experienced, and such a check is pro- 
duced in the rhythmical contractions of the sexual tract that the 
typical sensation is obtunded or is absent. 



202 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

In very old and extensive modular strictures of the bulbo-mem- 
branous junction there is no post-coitional flow of semen, and this 
secretion then passes backward into the bladder and is mixed and 
expelled with the urine, which then has a very milky appearance. 
When these cases are complicated with one or more perineal fistulas 
the semen passes into the tracts and oozes over the ano-perineal 
region. 

Strictures at the peno-scrotal angle in the anterior urethra cause 
impediment to the escape of semen in proportion to the smallness 
of their calibre. When the contraction is very slight little hin- 
derance to ejaculation is offered, but when it reaches the degree of 
reduction in calibre of 10 or 15 French then imperfect and defec- 
tive expulsion may be produced, and post-coitional dribbling may 
occur. In these cases, even when the stenosis of the urethra is 
quite complete, there is no reflux of semen into the bladder, and 
it, when the parts become relaxed, slowly dribbles from the meatus. 
In several of these cases the patients have told me that after coitus 
they experienced a sensation of fulness in the perineum, which was 
only relieved by compressive manipulation, which caused the semen 
to gradually escape forward. 

In those somewhat rare cases in which the whole anterior ure- 
thra is the seat of tight stricture ejaculation is very imperfect and 
halting, and such subjects are practically aspermatous. 

Stricture at the meatus, which is the result usually of chan- 
croids, chancres, gangrene, warts, chemical and instrumental trau- 
matism, and perhaps of gonorrhoea, may lead to the various grades 
of aspermatism, from slight and feeble discharge to post-coitional 
dribbling, or even to the damming back of the ejaculate. In these 
cases the urine usually escapes in a fine stream, but in coitus, with 
its turgescence of the mucous membrane and a secretion of much 
greater density passing through the stricture, the conditions are so 
altered that more or less perfect aspermatism results. 

Stenosis, or smallness of the preputial orifice, whether congen- 
ital or acquired, is not infrequently the cause of varying degrees 
of aspermatism. Patients having this form of phimosis usually 
state that in their earlier sexual years ejaculations were satisfac- 



ASPERMATISM. 203 

tory, and, to their mind, unimpeded. As they grow old the stenosed 
condition usually becomes more pronounced, and with the dimin- 
ishing calibre of the preputial orifice the various grades of morbid 
emission, from defective and impeded ejaculation up to complete 
asperniatisru, are produced. 

The probable explanation of these cases of stenosis of the meatus 
urinarius and of the prepuce, which are quite permeable to the 
escape of urine, and which offer an impediment to spermatic emis- 
sion, is that the urine is a much thinner fluid than the semen, and 
that in urination the vis a tergo is greater than in coitus. 

It is well to remember that after coitus, in almost all cases of 
aspermatism, there is the escape of a few drops of clear mucus 
from the meatus, which is secreted by the urethral muciparous 
follicles and crypts and by Cowper's glands. 

Fig. 54. 




Urethral calculus composed of phosphate of lime. Natural size. Calculus 
consisted of four articulated segments. (Dolbeau. ) 

Preputial calculi may be the cause of organic impotence or of 
temporary aspermatism. 

Calculi are sometimes found in the urethra, where they may 
increase to such a size that blocking up of the canal is produced. 
(See Fig. 54.) In such cases the impediment to urination may be 
tolerably well marked, but the escape of semen is so much retarded 
that incomplete or difficult ejaculations, or actual aspermatism, 
may result. These calculi may be seated in the bulbous urethra 
at the peno-scrotal angle or in the course of the anterior urethra. 

Many men suffering from priapism, while capable of intromis- 
sion, fail in the act of ejaculation. They are, therefore, tem- 
porarily at least, aspermatous. 



204 SEXUAL DISORDERS OF THE MALE AND FEMALE. 



ANOMALOUS CASES OF ASPERMATISM. 

Two anomalous cases of aspermatism have been reported by Ultz- 
mann. 1 The first was that of a man, forty years of age, who, 
though married, had never been able to produce semen. During 
coitus he experienced the sensation of ejaculation and felt a 
kind of satisfaction. His testicles were small, but his genital 
organs were pronounced by Ultzmann to be perfect. It was 
proved by examination of the urine that the semen in coitus did 
not regurgitate into the bladder. 

The second case was that of a robust man, aged twenty-four 
years, who was potent as to coitus, but had never had an ejacula- 
tion or a pollution. He had never had any sexual desire, and his 
genital organs were pronounced to be normal. He remained per- 
manently aspermatous. 

Belkowsy describes the case of a man who, although married 
for four years, had never been able to perform the sexual act. In 
spite of the fact that his genitals were normal in development and 
his general bodily condition was excellent, he was totally devoid 
of sexual sensations, had never in his life had erections, and only 
quite lately had he had some nocturnal emissions (consisting in 
all probability of the secretion of Cowper's glands), accompanied, 
however, by only imperfect erections. He was totally indifferent 
to the female sex, but no trace of sexual perversion could be 
observed. 

Such cases as the foregoing are paradoxes, and the attempt to 
explain them on the ground of non-excitability of the reflex 
centre of ejaculation (the existence of which has not been proved) 
is very unsatisfactory. Cases have been reported, however, in 
which it is probable that disease or traumatism of the nervous 
system resulted in aspermatism. Thus the old-time case of the 
soldier, who, as a result of concussion of the spine, was affected 
with complete anaesthesia of the external genitals, and asperm- 
atism in coitus, although he had nocturnal pollutions, presents a 

1 Op. cit., pp. 116 et seq. 



A SPERM A TISM. 205 

clear and intelligible clinical picture. Other cases are on record 
in which anaesthesia of the glans penis was the cause of temporary 
asperntatisin, but they are so lacking in essential details as to 
possess but little value. 

In fibroid sclerosis of the corpora cavernosa anaesthesia of the 
glans sometimes occurs together with non-turgescence of the parts 
in sexual excitement and coitus. In such cases ejaculation may 
be difficult, incomplete, or entirely absent. 

In cases of destruction of the distal portion of the penis from 
chancroids, chancres, gangrene, and phagedena, such has been the 
anaesthesia or the insensitiveness of the parts produced that more 
or less complete aspermatism has followed, although the calibre 
of the urethra was not injuriously stenosed. 

Mutilating Meatotomy and Damage to the Urethra. 

I have seen two cases in which, after extensive and greatly de- 
forming meatotomy, an aspermatous condition was produced which 
the patients accounted for on the ground of unnatural insensitive- 
ness of the glans penis. In several cases of so-called strictures of 
large calibre, which were very much overdilated and deeply cut 
by zealous surgeons, these patients, besides suffering from decided 
curvature of the penis, experienced such queer and annoying 
sensations (tingling feelings and darting pains) in the urethra in 
coitus that partial ejaculation only occurred after very prolonged 
and tiresome efforts. 

Partial Aspermatism. 

Some men are temporarily aspermatous in consequence of the 
inhibitory action of the brain. In these cases men may have 
satisfactory coitus with some women and cannot complete the act 
with others. In other instances apathy, loss of affection, fear, 
disgust, peculiar environments and situations, unattractiveness of 
or some objectionable condition or habit in the female so affect a 
man's mind that, although erection occurs, ejaculation is impos- 
sible. These cases resemble in some particulars psychical impo- 



206 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

tence. (See p. 78 et seq.) In many of them the semen dribbles 
away after sexual excitement has subsided. 

Debility and Lack of Nerve-force. 

Then, again, some men are so weak and so much debilitated or 
mentally worried, that although erection, partial or complete, 
occurs, there is not sufficient nerve-force in them to call into 
vigorous action the intrinsic and extrinsic muscles of the sexual 
apparatus. This condition has been designated atonic asperma- 
tism, and it is not of necessity of permanent duration. In most 
cases it has been preceded by a period of full sexual activity. 

Diagnosis. In every case of aspermatism it is absolutely 
necessary to get a full history of the symptoms and antecedents 
of the case, and then to make a discriminating examination of all 
the segments of the sexual tract. In all cases a thorough exam- 
ination of the urine should be made. When the symptoms point 
to lesions of the ampullaa and seminal vesicles, exploration of these 
parts and examination of the urine are necessary. If the trouble 
is seated in the ejaculatory ducts, the question arises, Has the 
patient had gonorrhoea, or abscess of the prostate, or is the dis- 
ability due to plugging up by concretions or calculi ? An intelli- 
gent and searching inquiry on these subjects will usually elicit 
important information. Lesions of the prostate being so often 
the cause of aspermatism, inquiry into the antecedents of the case 
and rectal examination of that gland are to be made. 

In most cases of stricture of the urethra symptoms referable to 
that condition will coexist with the aspermatism, and then a care- 
ful exploration of the urethral canal should be made. These same 
remarks apply to instances of urethral calculi. 

In the cases which in this chapter have been denominated 
anomalous the most searching inquiry into and exploration of the 
sexual sphere should be made, in order to find out whether there 
are any malformations or obscure conditions produced by disease. 
It is usually very easy to learn concerning nerve-traumatism, and 
when mutilation or destruction of the penis exists careful exam- 
ination will reveal its nature and extent. 



ASPERMATISM. 207 

Prognosis. In general, the prognosis of aspermatism is not 
encouraging, particularly if due to malformations. When great 
structural damage has been done (seminal vesicles, ampullae, ejacu- 
latory ducts, and prostate gland) little hope can be offered to the 
patient of his reacquiring good sexual ability. 

Calculi in the prostate or ejaculatory ducts can be removed by 
operation. In the milder forms of stricture of the urethra, and 
even in severe forms, cure of aspermatism can be brought about 
by the re-establishment of the calibre of the urethra. In the very 
old cases of nodular stricture at the bulbo-membranous junction, 
particularly when complicated by perineal fistulse, it is hazardous 
to give a favorable prognosis. 

When the meatus or the urethra has been permanently damaged 
by ill-advised surgical procedures surgery offers very little in the 
way of relief. In some cases of very extensive meatotomy the 
parts may be restored by proper surgical technique. 

Treatment. In all the foregoing cases in which serious struc- 
tural changes are present in the deep sexual tract little of real 
benefit can be done by surgical means. 

Calculi may be removed from the deep urethra, the prostate, 
and ejaculatory ducts either by the urethral forceps, the lithotrite, 
or by external urethrotomy. 

Stricture of the urethra, if of the soft variety, may be cured by 
instillations of nitrate of silver and by careful gradual dilatation. 
Inodular strictures and quite dense annular strictures call for either 
internal or external urethrotomy. 

Cases of aspermatism due to the inhibitory influence of the brain 
should be carefully inquired into, and when the exciting cause is 
ascertained, its avoidance or removal will, in all probability, be 
promptly followed by normal ejaculation. 

When severe stenosis of the meatus urinarius is present the 
resulting aspermatism may be promptly relieved by a properly 
performed meatotomy. In like manner, in cases of pinhole-sized 
preputial orifice, circumcision is followed by very gratifying 
results. 



CHAPTER XVII. 

CHRONIC INFLAMMATION OF THE BULBOUS AND PROSTATIC 
URETHRA, STENOSIS, AND STRICTURES. 

So many cases of sexual weakness and impotence are due to 
structural changes in the deep portions of the urethra that a 
knowledge of these morbid conditions and of the methods of their 
scientific treatment is absolutely necessary. 

CHRONIC INFLAMMATION OF THE BULBOUS 
URETHRA. 

In the bulbous urethra the gonorrheal process shows a marked 
tendency to become chronic, and its persistency causes it to be very 
rebellious to treatment. In this part of the urethra the vascular 
supply is so great, the tissues are so succulent, and, we may say, 
relaxed, that every condition favorable to chronic inflammation is 
there present. 

Chronic urethritis of the bulbous urethra may give rise to no 
secretion visible at the meatus. Then, again, the pus may be so 
copious and fluid in consistence that it may glue up the meatus 
in the morning and perhaps during the day, or may escape once 
a day or oftener as a decided drop. Owing to the fact that the 
bulbous portion is in direct continuity with the membranous ure- 
thra this portion may be the seat of hyperemia or inflammation 
in bulbous urethritis. 

Chronic urethritis of the bulb runs a markedly protracted course. 
For a time there may be no impediment to urination, and the only 
symptoms may be the slight discharge, or even gonorrheal threads, 
in the morning urine, and perhaps uneasy, even burning, sensation 
in the perineum. In many cases early in the chronic stage there 
may be no disturbance in the sexual function ; but as time goes 






CHRONIC INFLAMMATION OF THE URETHRA. 209 

on, and the calibre of the bulbous urethra becomes lessened, more 
or less sexual debility may occur. It is well, however, to empha- 
size the fact that in many cases in which the bulb is much involved 
no sexual weakness is noted. 

At the bulbous portion of the urethra, with the expanded and 
much thicker spongy body encircling it, the round-cell infiltration 
into the submucous connective tissue layer, caused by gonorrhoea, 
becomes more exuberant than elsewhere. The tissues are here 
soft and succulent, and the blood-supply is copious. Moreover, 
there is no firm, fibrous capsule around the bulb ; therefore, there 
is not that hinderance to profuse hyperemia and inflammation that 
there would be if the parts were quite firmly invested in a capsule 
of dense tissue. For these reasons the post-gonorrhoeal inflam- 
matory process is severe and long-lasting, and its resulting cell- 
infiltration exuberant and extensive. In the bulb, therefore, the 
infiltration is at first in the submucous connective tissue, and later 
on it becomes inextricably mixed with muscular and elastic fibres 
and vessels, and the condition called soft stricture then results. 
The morbid condition then consists of round-cell infiltration with 
a tendency to the development of fibrous tissue. When this fibrous 
tissue is developed, and when tolerably copious and intermixed 
with the round-cell infiltration, the resulting contraction is of 
semifibrous structure. Then, as time goes on and the morbid 
process increases very decidedly in extent and depth, the newly- 
formed fibrous tissue takes the place of the erectile and vascular 
tissues, the areolae are obliterated, and the normal structure of the 
parts becomes wholly lost and replaced by a uniform sclerotic and 
atrophic fibrous tissue, white, firm, and homogeneous in structure, 
which constitutes what is called modular stricture. 

It will be thus seen that in the bulbous portion of the urethra 
we find varying grades in the extent and the intensity of the same 
morbid process. The determination of the existence of these mor- 
bid stages is to be arrived at by means of urethral examinations 
with the bougie a boule or the olivary bougie. 

Xo precise statements can be made as to the rapidity of growth 
of the gonorrhoea! infiltration into the bulbous urethra. 

14 



210 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

In sonic quite exceptional cases the cell -proliferation is quite 
active, and in about six months the calibre of the canal at this 
point may be reduced to 15 of the French scale, or even to 
smaller size. In cases of loss of calibre there may be experi- 
enced some inability to normally expel the urine. As a rule, the 
process grows quite slowly, and months, and even years, may 
elapse before very marked contraction occurs. In many such 
cases there may be some loss of sexual desire. In general, how- 
ever, when these patients complain of an impediment in the 
sexual function, they say that toward the end of ejaculation some- 
thing seems wrong, and that the act is not performed so promptly 
and satisfactorily as in earlier days. The reason for this func- 
tional impairment is largely a mechanical one. As we have already 
seen (see page 59), in ejaculation the secretion is thrown from the 
prostate into the capacious bulb of the urethra, and that then the 
intrinsic and extrinsic muscles contract powerfully and send the 
ejaculate out of the meatus. Now, in chronic urethritis of the 
bulbous portion the walls of the canal at this part become more 
and more rigid, and consequently less expansible, and the invol- 
untary muscular fibres, which usually exert a powerful action, lose 
more or less of their contractile force. Therefore, when the copious 
ejaculate reaches this segment of the canal the latter can only be 
moderately, if at all, expanded by the volume of the secretion, 
and, thus crippled, can only exert a moderate, if indeed any, ex- 
pulsive force upon it. Thus ejaculation becomes lame and halting 
just before its completion, and this impediment may cause much 
disturbance in the mind of the patient. 

With the increasing diminution in the calibre of the urethra at 
this point the difficulty in urination increases, and there is a total 
loss of extensibility and of contraction of the canal during coitus. 

As the soft stricture tissue increases in quantity and density the 
rigidity and inextensibility of the canal become more marked in 
the semifibrous and fibrous stages. Then, as the stenosis of the 
canal increases until an inodular stricture is produced, its calibre 
becomes so small that urine may escape with difficulty in a small 
stream or in drops, and the seminal ejaculate in coitus may be so 



CHRONIC INFLAMMATION OF THE URETHRA. 211 

barred that it cannot go forward, and flows back into the bladder. 
In this event the patient is aspermatous. 

In many cases of this chronic, gradually stenosing inflammation 
of the bulbous urethra, besides the increasing impediment to the 
sexual act, there seems to be developed some peculiar reflex con- 
dition, perhaps in the sexual centre, which results in a greater or 
less condition of impotence. This form of impotence usually de- 
velops slowly, and in very many cases it disappears more or less 
promptly when proper treatment is instituted and faithfully fol- 
lowed up. 

CHRONIC POSTERIOR URETHRITIS. 

Chronic posterior urethritis follows in many cases the subsidence 
of the acute process. Owing to the complexity of structure of the 
posterior urethra the symptomatology of this affection is often well 
marked. When there is simply uncomplicated chronic inflamma- 
tion of the mucous membrane the symptoms may be negative or 
very slight in character. But when the prostatic sinuses, the 
orifices of the ejaculatory ducts, the utriculus masculinus, and the 
caput gallinaginis are, together or in part, the seat of trouble, we 
find a varied group of symptoms referable to the sexual apparatus 
and its function. 

In chronic urethritis distinctly limited to the posterior urethra 
there is usually no escape of pus into the anterior portion, for the 
reason that it is small in quantity and viscid in consistency. There 
are, however, border-line cases in the extreme terminal stage of 
the acute affection in which the pus is still rather copious, and it 
escapes through the membranous urethra and passes toward the 
glans. The compressor urethral muscle does not, as claimed by 
some authors, usually contract the lumen of the urethra to a hair- 
sized calibre, and in general it is a moderately patulous canal at 
this point. There certainly is not, in the majority of cases, such 
a tonicity of the compressor urethra? muscle as will keep back a 
quite copious discharge. While in many cases, owing to its small 
quantity, the pus may be retained in the posterior urethra by the 
cut-off muscle, in some cases it certainly is not thus dammed back- 



212 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

ward. The cases of chronic posterior urethritis in which a dis- 
charge reaches the meatus are very rare, but they occur. 

In very many cases of posterior urethritis, there being no visible 
discharge and the patient complaining of no symptoms referable 
to the deep urethra, the affection remains dormant, latent, and 
unrecognized. Thus the cases may drag on for one or more, and 
even five, ten, and fifteen, years without giving any indication of 
lurking trouble. In some of these cases an exacerbation may 
occur, and then the patient realizes that he has had an uncured 
gonorrhoea. In many cases the first disturbing symptom is a 
greater or less loss of or defect in the sexual function, and exam- 
ination shows that chronic posterior urethritis has existed perhaps 
for a long time. 

In some instances the exacerbation of the posterior urethritis 
is subacute in character, attended only with mild or insignificant 
symptoms, and its presence would not be suspected or sought for 
had not an attack of epididymitis or epididymo-orchitis developed 
as a complication. In many cases of this deep-seated urethritis, 
in which epididymitis or epididymo-orchitis is developed in the 
initial attack, recrudescences in the testicular trouble are frequently 
observed at late and remote periods as a result of an exacerba- 
tion in the posterior urethra. In these cases sexual debility may 
result from the urethral trouble, while the recurring inflammation 
of the testes and epididymis may cause azoospermatism. 

In somewhat rare instances chronic posterior urethritis, usually 
as a result of excesses, become developed into a true acute attack 
with all its symptoms and its discomforts. It may then run its 
course, but in some cases the inflammatory process extends forward 
into the anterior urethra, which also becomes the seat of an acute 
phlegmasia. In these cases, when the discharge is well estab- 
lished in the anterior urethra, the sufferings of the patient, expe- 
rienced when the posterior segment alone was affected, cease, and 
the case then takes on the features of gonorrhoea of the totality 
of the urethra in its declining stage. 

Symptoms. The symptoms of chronic posterior urethritis are 
many and varied, mild and severe. 



CHRONIC INFLAMMATION OF THE URETHRA. 213 

This affection was formerly rather vaguely understood, and to it 
the names of neuralgia of the bladder, neuralgia of the neck of 
the bladder, and irritability of the bladder have been given. In 
the light of modern study all these names may be dispensed with, 
and the term " chronic posterior urethritis " may be retained. 

Cases of this affection may be, for purposes of study, separated 
into groups according to the nature and severity of their symptoms. 

There are found in practice a goodly number of cases in which 
a frequent desire to urinate and some uneasiness at the end of the 
act, and sometimes at its beginning, are the only symptoms com- 
plained of. In some of these cases the increased frequency in 
urination is not much above normal ; in others it is well marked. 
In some cases the pain is slight and dull, or of a quick, stabbing, 
but very ephemeral character. In others it is dull, heavy, per- 
haps spasmodic, and radiates into the rectum, pelvis, testes, and 
groins. In these cases the act of urination may go on smoothly, 
or it may be interrupted by slight or severe spasm of the com- 
pressor urethrae muscle or of the detrusor vesicae muscles. This 
condition has been called " cysto-spasnius." It is liable to occur 
after coitus or difficult defecation. In other cases there is no dis- 
turbance of urination at all, but patients complain of dull or aching 
pain in the perineum, deep in the pelvis and prostate, and in the 
rectum. Sometimes these patients complain of pain over the 
pubes, and of uneasy, vague pains in the cord and testes. In 
some cases mild and even severe neuralgic pains are complained 
of in the loins, groins, and thighs. These painful symptoms, par- 
ticularly when severe, are, fortunately, not always present. They 
vary from day to day, so that the patient has intervals of com- 
parative comfort. 

Chronic posterior urethritis may exist for many years (five to 
twenty), and yet the patient may regard himself as free from all 
gonorrheal sequelae. In some of these cases sexual and alcoholic 
excesses excite exacerbations of the urethritis, which usually yield 
quite readily to treatment. In other and exceptional cases the 
first symptom of the existence of the chronic trouble is more or 
less profuse haematuria, which, as a rule, occurs after or toward 



214 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

the end of urination. In some cases the onset of sexual weakness 
is the first sign of disease in the posterior urethra. 

Diagnosis. The diagnosis of chronic posterior urethritis can 
usually be clearly established by eliciting the history of an earlier 
acute affection. 

Fig. 55. 




Showing the microscopic appearance of the secretion of posterior urethritis. 



In chronic posterior urethritis the amount of morbid secretion 
is usually very small, hence the two-glass test of the urine, which 
gives such clear indications in acute posterior urethritis, cannot 
be relied upon as an infallible guide. If this test is used in the 
chronic affection, the first part of the morning urine will contain 
threads, while the second will be clear ; but in such an examina- 
tion it may occur that tissue-elements from the anterior urethra 
will also be present in the urine. The best plan is to carefully 



CHRONIC INFLAMMATION OF THE URETHRA. 215 

wash out the anterior urethra as far as the triangular ligament 
with warm water ; then, when the urine is passed, if it contains 
threads, it is quite certain that they come from the posterior urethra. 

In this connection it is well to remember that small, comma-like, 
fleecy plugs or threads, which are thought to be formed in the ex- 
cretory ducts of the prostatic glands and voided with the last drops 
of urine, being pressed out by muscular and prostatic contraction, 
are quite diagnostic of chronic posterior urethritis. (See Fig. 55.) 

Perhaps the most serious and, for the physician, trying cases of 
posterior urethritis, even in those in which no trouble of the pros- 
tate can be found on careful examination, are those in which there 
is some disturbance of the sexual function. Some patients com- 
plain of a severe stabbing pain at the moment of or after ejacu- 
lation of the semen. Others state that all pleasurable sensations 
are either absent or lessened in degree in sexual intercourse, and 
they are thereby much worried. In still other cases the ejacula- 
tions occur before intromission or shortly afterward. 

In some cases pollutions are frequent, and with their occurrence 
diminution in the sexual appetite may be felt. Many of these 
patients become weak, nervous, and apprehensive. Their diges- 
tion becomes poor, and they suffer from constipation. Then the 
passage of a hard fecal plug presses the prostate and expels the 
accumulated muco-pus, which appears at the meatus, causing the 
patient to think he is losing semen. In some of these cases some 
of the secretion of the seminal vesicles is at the same time expelled, 
and this also to many is convincing proof that they are suffering 
from spermatorrhoea. Occasionally these patients are much alarmed 
at the occurrence of bloody pollutions, which are due to great 
hyperemia of the ejaculatory ducts and the prostatic and bulbous 
urethra, and sometimes the seminal vesicles. In any of these 
cases of disturbance of the sexual function we are liable to find 
more or less deterioration of the health. This may consist simply 
of weakness and lassitude, and it may be a condition of great 
nervousness, of melancholia, or even of true neurasthenia. Be- 
tween these two extremes there are many degrees of bodily and 
mental debility. 



216 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

The foregoing symptom-complex may be found in cases in 
which, as has been stated before, careful examination will show 
that the prostate is not synchronously the seat of chronic inflam- 
mation. But in other cases true posterior urethritis with chronic 
prostatitis may exist, and the patient may complain of the symp- 
toms as just now detailed. 

Pathological Appearances. The most constant morbid con- 
dition seen in chronic bulbous urethritis is a rather deep-red, even 
purplish, color of the mucous membrane, which is more or less 
thickened. This redness may involve a segment of the canal or 
a limited portion on one or two sides. In these cases more or less 
pus, thin or inspissated, may be seen in the examination. Thick- 
ened, red, circumscribed spots or plaques of chronic inflammation 
are very common. Another appearance quite commonly seen is 
called by some granular urethritis. The membrane is thickened, 
red, even purplish in streaks, and rough and studded with small 
projections, which consist either of epithelial hyperplasia or of 
little eminences caused by the growth of new capillary vessels. 
This condition is frequently found in the bulbous urethra and also 
in the pendulous portion. 

The morbid appearances of the mucous membrane of the poste- 
rior urethra are conspicuously striking. They consist of thicken- 
ing, more or less papulation, together with increased redness. 
Frequently the caput gallinaginis and the orifices of the prostatic 
ducts are seen to be swollen. The underlying pathological process 
is precisely similar to that of the anterior urethra. 

Treatment. It is better to give here the treatment of chronic 
posterior urethritis from the period of decline of the gonorrhoeal 
process than to begin with the very late stages of posterior ure- 
thritis. 

The duration of the urethritis has an important bearing upon 
its treatment. Let us first consider the cases in which the disease 
has lasted only a few months. Such patients may complain only 
of the morning drop, or they may state that they seem well so 
long as they use an injection, abstain from coitus, and do not drink 
beer and alcoholics or eat highly seasoned food. When they cease 



CHRONIC INFLAMMATION OF THE URETHRA. 



217 



injecting and indulge in creature comforts and excesses the morn- 
ing drop reappears, with perhaps a more or less profuse discharge 
during the whole day. Examination of the urethra in these cases 
shows a catarrhal and exudative condition from the bulb forward, 
perhaps nearly to the meatus. In many of these cases the poste- 
rior urethra is also involved. The morning urine is rather cloudy, 
like turbid cider, contains much mucus and some long, thin or thick 
threads (sometimes three or four inches long). There may or may 
not be a few gonococci present. In these cases the best treatment 
is irrigation of the posterior and anterior urethra, using at first 
warm solutions of alum and sulphate of zinc or permanganate of 
potassium, beginning with a strength of 1 : 5000, and increasing 
according to the result obtained. 

Fig. 56. 



Reflux catheter. 
Fig. 57. 




Hand-syringe. 

The instruments necessary for these instillations of the bulbous 
urethra are a soft-rubber reflux catheter of a calibre of about 14 
to 16 French scale (see Fig. 56) and a hard-rubber hand-syringe. 
(See Fig. 57.) The end of the catheter should be passed down 
to the bulb, and then the nozzle of the syringe is inserted and the 
injection is given. For injecting the prostatic urethra the ordi- 
nary soft catheter should be cut off so that it measures eight and a 
half inches. (See Fig. 58.) This rubber catheter (10 to 12 French), 
lubricated with glycerin or lubrichondrin, is passed down the 



218 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

urethra until its eye enters the prostatic urethra, which is usually 
seveD or seven and a half inches down. The bladder being empty, 
pressure on the piston then throws the injection into the prostatic 
urethra. It is well now to withdraw the catheter a little until its 
end is in the membranous urethra ; then on pressing the piston 
gently resistance will be felt and no fluid will flow. This tells 
the surgeon that he is in the membranous urethra, and that the 
irritation of his procedure has caused the contraction of the com- 
pressor urethras muscle. Then push the catheter inward about 
half an inch and inject again, when the fluid will readily pass. 
By this manoeuvre the eye of the catheter is placed just at the 
apex of the prostate and at the very beginning of the prostatic 
urethra. The injection is then slowly thrown in, and it passes 
through the whole of the prostatic urethra into the bladder. If 
only a rather small injection is to be given, about one-half of the 
contents of the syringe may be used posteriorly. Then, while 
still pressing the piston, the surgeon gently draws out the cath- 
eter, and finds that as its eye passes through the membranous 
urethra the flow stops again, but is at once resumed when the 
eye reaches the bulbous urethra, which is then irrigated with the 
remainder of the fluid. 

Fig. 58. 




Soft-rubber catheter. 

Usually one irrigation several times a week is sufficient, but per- 
haps one each day may be well borne. The sensations of the 
patient and the condition of the urine are infallible guides as to 
the required frequency of treatment. As a general rule, after one 
or two weeks' treatment these irrigations seem to lose their efficacy, 
having done some good, but not having produced a cure. Per- 
haps in these conditions permanganate of potassium irrigations 



CHRONIC INFLAMMATION OF THE URETHRA. 219 

(always hot), 1 : 1000 or 1 : 2000, may bring about a cure. If this 
remedy fails we resort to nitrate of silver, beginning with solu- 
tions of the strength of 1: 16,000 or 1 : 8000, and sometimes even 
weaker ; and this usually results in a cure if the tretment is care- 
fully administered. If the morbid process is more severe in the 
anterior urethra, the bulbous reflux catheter should be introduced 
as far as the bulb, and one or two syringefuls of the irrigating 
fluid should be injected. The posterior urethra should then be 
similarly treated. Sometimes it is necessary to finish with quite 
strong, deep injections. In these cases much pain is frequently 
produced by the passing of sounds, particularly of large ones. 
This fact should always be borne in mind, since many patients 
thus treated suffer severely, Avhile in others the disease is so 
aggravated that it becomes most difficult to cure. Some of these 
cases are thus rendered practically incurable even when the most 
judicious and prolonged treatment is followed. Too much attention 
cannot be paid to the fact that in some cases of chronic gonorrhoea 
sounds, particularly large ones, may be productive of incalculable 
harm when used too early. 

When the disease is limited to the bulbous portion, where it 
shows a great tendency to remain indefinitely, the retrojections of 
alum, sulphate of zinc, and nitrate of silver may be used. These 
injections will materially modify the morbid process, and some- 
times cure it, but they often fail to bring about a thorough cure. 
In that event it is well to make direct local applications of solu- 
tions of nitrate of silver, beginning with a solution of 1 : 2000, 
and perhaps going as high as 1: 250 and 1: 125. 

A very useful and perfectly effective syringe is the one gener- 
ally used by me. (See Fig. 59.) There is nothing whatever 
original about this syringe. It is simply a well-made instrument, 
very easily worked, having a ring and shoulders for the thumb and 
fingers, and a very conical nozzle, which will fit into a small, soft 
catheter. The piston is marked with numbers to regulate the 
drops. The injecting medium is any well-made soft-rubber cath- 
eter, 10 to 12 or 14 French, cut off to measure eight and a half 
inches in length. When the catheter is introduced six or six and a 



220 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

half inches its end is in the sinus of the bulb, aud the very slight 
Impediment it encounters there shows the operator that he is just 
at the opening in the triangular ligament. 



Fig 




Author's syringe. 



This little catheter, when slowly passed, causes no pain or irri- 
tation. Then ten or fifteen drops of the silver nitrate solution 
may be thrown into the urethra. This treatment may sometimes 
be varied by using 1, 2, or 3 per cent, sulphate of copper solution, 
or a 1 : 1000 permanganate solution. This treatment may be 
administered by the surgeon every five days or twice a week, and 
perhaps oftener if the indications of the case point to the necessity 
of increased frequency. In the intervals the patient may use mild 
stimulant and astringent injections by means of a penis-syringe. 
This form of chronic urethritis being very rebellious, it is some- 
times necessary to pass an endoscopic tube down to the bulb (see 
Fig. 60), and having ascertained the morbid appearances, to 
sparingly apply on cotton at the end of an applicator a strong 
solution of silver nitrate (thirty to sixty grains to one ounce of 
water). 

Fig. 60. 




Endoscopic tube. 



In the more chronic cases of anterior urethritis we find spots, 
patches, and areas of inflammation at the peno-scrotal angle (some- 
times seemingly caused by the pressure of the suspensory worn 



CHRONIC INFLAMMATION OF THE URETHRA. 221 

during the declining stage) and in the pendulous urethra as far as 
its beginning. 

The first essential in the treatment of these cases is to locate the 
trouble and to determine its nature. Now, in this part we find 
subepithelial infiltration, with or without a greater or less epithe- 
lial hyperplasia, erosions, and superficial ulcerations, always accom- 
panied with submucous thickenings and follicular inflammation. 
The thickened mucosa may be granular, villous, or papillomatous. 
The urine can do little in enlightening us as to the exact nature of 
the morbid process unless it contains old flabby and fatty epithe- 
lial cells, which point to an old ulcer which is in too atonic a con- 
dition to heal of itself. In these cases much aid can be obtained 

Fig. 61. 




Bougie a boule. 

as to location by the bougie d, boule. This instrument consists of 
a conical or acorn-shaped head with a well-marked sharp but 
gently rounded shoulder, which is attached to a flexible gum- 
elastic staff. (See Fig. 61.) For the cases under consideration 
we may need these bougies a boule in size ranging from 18 to 30 
French. For strictures we may use the smaller sizes, which begin 
as small as 8 or 10 French. 

In the treatment of posterior urethritis with or without anterior 
urethritis great care is required to determine as nearly as possible 
the exact condition of affairs. In the more recent cases we some- 
times find some evidence of bladder incompetence (the urine show- 
ing no involvement of that viscus), which shows itself by the 



222 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

escape of a little (two drachms to one-half ounce or more) residual 
urine when the eye of the catheter reaches the neck of the bladder. 
Iu these rather early cases mild irrigations of the astringents and 
of permanganate of potassium may be used, and perhaps with 
benefit. The most uniformly effective agent here also is the 
nitrate of silver, which may at first be used well diluted, 1 : 16,000 
or 1 : 8000, in the form of hot irrigations. 

For older and very chronic cases of posterior urethritis the 
stronger silver nitrate injections, 1 : 500 or 1 : 250, may be used. 
In my experience, fifteen drops or more of these solutions produce 
better effects than a more sparing injection of stronger solutions. 
These injections should be given every third or fourth day. They 
may, however, produce benefit in some cases if made more fre- 
quently. Daily injections are liable to cause acute suppuration, 
w T hich means irritation, and that must be avoided. 

Posterior urethritis, accompanied by sexual disability, premature 
ejaculations, pollutions, and absence of erections and loss of sexual 
desire, usually require the injection of a few drops of the stronger 
solutions just mentioned. 

Treatment of Stenosis and Strictures of the Bulbous Urethra. 

Stenosis and stricture of the bulbous portion of the urethra may 
be soft, semifibrous, fibrous, and i nodular, all of which require 
appropriate treatment. 

Soft and semifibrous strictures should, as a rule, never be incised 
until milder means have been tried and have failed. 

The diagnosis having been carefully made, the calibre of the 
stricture is to be determined. Now, on this point no rule can be 
laid down, since cases differ so strikingly. Thus in some patients 
the canal may be reduced to 20 or 15 F., and yet these strictures 
are of the soft variety. In others, with similar calibres, they may 
be semifibrous or fibrous. Then, again, it is not very uncommon 
to find a urethra reduced to even 6 or 8 F. by an exudative hyper- 
plasia, which we call soft stricture. These various and varying 
conditions have to be ascertained, and as the surgeon grows in 



CHRONIC INFLAMMATION OF THE URETHRA. 223 

experience lie will become more and more expert in recognizing 
them. 

Gradual Dilatation. When the stricture in the bulbous urethra 
is yet in the soft, or even in the semifibrous, stage, the aim should 
be to remove as far as possible the cell-infiltration, and thus, in a 
manner, to restore the mucous membrane to its natural condition. 
This can be done in many cases by careful and gradual dilatation. 

Seeing that a soft stricture may contract the urethral lumen 
even as low as 7 or 8 F., and that in many cases where the calibre 
is 15 or 20 F. the infiltration is yet soft and succulent, it is always 
well to make the attempt to cure by the introduction of the bougie 
or sound before the knife is resorted to. When, however, a fibrous 
or modular stricture of small calibre is discovered our chief thought 
is not toward gradual dilatation. 

I have in so many instances been able to restore the urethra 
even when contracted to 7 or 8, to 30 F., that I am always 
loath to operate more radically. 

In the process of gradual dilatation much care, patience, and 
good judgment are necessary. The operation should always be 
carefully and slowly performed in a manner to cause no pain or 
uneasiness and no damage to the tissues. By the pressure and 
stimulation of the distending instrument we hope to cause the 
absorption of the exudation and to give tone and resiliency to the 
dilated vessels. It will thus be seen that we are always liable to 
cause inflammation, and this condition will either delay the cure 
or perhaps thwart our efforts. In cases where the contraction is 
as great as 7 or 8 F., and also where the calibre of the stricture 
is much larger, there may be posterior urethritis or even urethro- 
cystitis, and these conditions should then receive proper treatment. 

Beginning with a small olivary bougie (see Fig. 62), the surgeon 
should gradually and slowly increase the size of the instrument as 
the progress of the case will indicate to him. In the early part 
of the treatment the bougie may be introduced once a week, and 
then in favorable conditions the interval may be fixed at about 
five days. It is almost always well to allow this interval of time 
to elapse between the seances of treatment. Many men have failed 



224 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

in this method of treating stricture by the too frequent introduc- 
tion of the instrument, and many patients have not received the 
benefit they would have had if there had been less haste. In 
gradual dilatation, particularly in the early stages, the sensations 
of the patient should be carefully considered and the urine regu- 
larly and methodically examined. If the operation causes uneasi- 
ness and pain in the perineum and over the pubes, and continued 
frequency in urination, and if the parts resist the gradual increase 
in the size of the instrument, it will be necessary to suspend the 
treatment temporarily, and perhaps permanently. In many of 
these cases local medication to the anterior and posterior urethra 
will put the parts in such a condition that gradually dilatation 
may again be resumed. 

Fig. 62. 



Flexible olivary bougie. 

It will be generally found, when dilatation is commenced, in 
the form of stricture under consideration, with very small olivary 
bougies, that at first the sizes may be increased quite regularly, 
and no trouble, or perhaps very little, is experienced by the sur- 
geon until he gets up as high as 20 or 22 F. Then he will gen- 
erally find that the dilating process goes on much more slowly, 
and that it may be necessary to introduce sounds of one size 
several times before larger ones can be used. 

The prompt and usually perceptible effect produced by the early 
systematic production of small bougies has much bearing on the 
future of the case. Patients watch the progress made step by step, 
and as they see that they are gaining in urethral calibre, and that 
they have lost their unpleasant symptoms (urethral or vesical), they 
become sanguine of an eventful cure, and present themselves regu- 
larly for treatment. It is most essential in these cases that the 
patient should have implicit confidence in the surgeon, and that he 
should keep his moral courage up in the ordeal through which he 



CHRONIC INFLAMMATION OF THE URETHRA. 225 

is passing. Though these patients are neither hurt nor inconveni- 
enced, the irksomeness of having at stated intervals to go to the 
surgeon is very trying to some. Others, and indeed the majority, 
appreciating the infirmities and sufferings which strictures almost 
inevitably lead to, resolve to keep on till they are cured. The main, 
and indeed the only, valid objections to gradual dilatation are that 
it is a slow process and occupies a quite long stretch of time. But 
it must always be remembered that if it is followed up until the 
urethra is restored to a calibre of 30 F., in the majority of cases 
it will only be necessary to have sounds introduced once or twice 
a year thereafter ; whereas it can be said, without fear of contra- 
ction, that when a man's urethra has once been cut he has (if he 
would keep the channel open) to pass instruments at short inter- 
vals all his life. All these considerations should be presented by 
the surgeon to his patient as the treatment goes on. Men often 
get careless and even indifferent at the time when they may be 
said to be about half -cured. In these circumstances the surgeon 
should use all his influence against faltering and backsliding. 

Fig. 63. 



Conical steel sound. 

When in the course of this treatment the urethra will admit an 
olivary bougie No. 20 F., it is well to resort to the curved steel 
sounds (see Fig. 63), and with them finish the cure. In many 
cases when the coarctation is extensive and involves the whole 
length of the bulbous urethra, the Beneque sound will produce 
particularly good results. (See Fig. 64.) Its double curve seems 
to exert a beneficial pressure not obtainable by the use of the 
ordinary curved sound. 

The trend of thought as regards the treatment of urethral 
stricture of late years has been so unswervingly toward cutting 

15 



226 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

operations that many surgeons are wholly unaware of the benefi- 
cent and lasting effects of gradual dilatation. I am to-day more 
than ever convinced that cutting operations should be a last resort, 
and that intemperate incisions and over-stretching are very fre- 
quently the cause of never-ending suffering and inconveniences. 

Fig. 64. 




Beneque's sound. 

It is impossible to state exactly the period of time necessary for 
cure by gradual dilatation, since it varies in each case, and so 
much depends on the regularity and sedulousness of the patient. 
In some cases the normal urethral lumen may be restored in three 
months, and in others in six, nine, and twelve months. As a 
general rule, a six months' treatment will be followed by better 
results than a shorter course. 

There is one point which deserves especial emphasis, and it is 
this : To produce satisfactory permanent results by gradual dila- 
tation the urethral canal must be brought up to the calibre of 30 
or perhaps 32 F., and when this is attained the dilating process 
must be continued for some time, until these large sounds pass 
easily and without any grasping. 

Continuous dilatation is very rarely resorted to at the preseut 
time. In some cases where a filiform has after a long struggle 
been passed through the stricture, it may be retained there for 
some hours, or perhaps for a day, in order to render certain the 
passage of a larger instrument. 

In the majority of cases the process of cure by gradual dila- 
tation is uneventful, but in a small minority certain complications 
may arise and give more or less trouble. These complications are : 
1, fever and chills ; 2, urethritis and urethrocystitis ; 3, a ten- 



CHRONIC INFLAMMATION OF THE URETHRA. 227 

dency to hemorrhage ; 4, temporary retention ; 5, rheumatism ; 
and 6, pyamric abscesses. It is well to state in advance that since 
the beginning of the era of asepsis and antisepsis in surgery these 
complications occur much less frequently than formerly, and they 
are much less severe. 

The occurrence of chills and fever shows that there is a low 
grade of suppuration in the deep urethra, but it need not cause 
the permanent discontinuance of dilatation. Such cases should be 
treated on the lines laid down for chronic anterior and posterior 
urethritis and urethrocystitis. 

When the sound causes inflammatory reaction its use should 
be discontinued until appropriate treatment removes the tendency 
thereto, as it will do in most cases. Exceptionally, however, it 
happens that the resulting inflammation is so great and so con- 
stant that it is necessary to wholly abandon this form of treat- 
ment. In many such cases judicious topical urethral medication 
after a time brings about such a change that the sound may be 
used again. In some severe and exceptional cases the expediency 
of external urethrotomy will suggest itself to the mind of the sur- 
geon. 

In like manner, the tendency to slight oozing of blood after 
dilatation can generally be checked by the instillation of a few 
drops of a solution of nitrate of silver (1 : 250). 

AVhen in the course of gradual dilatation retention of urine 
occurs once or at intervals it is perfectly certain that one or two 
causes are at work ; these are swelling of the mucous membrane 
in and near the stricture and temporary spasm of the compressor 
urethral muscle. In such cases there is need of topical urethral 
medication, and the intervals between the passage of the bougies 
or sounds should be materially lengthened. AVhen carefully man- 
aged this complication may be overcome. 

The occurrence of rheumatism and of pyemic abscesses indi- 
cates very clearly that, besides the stricture process, a decided 
suppuration of the urethra also exists, which can be cured by the 
means described in the section on the treatment of chronic ante- 
rior and posterior urethritis. 



228 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

It will be seen, therefore, that in the successful employment of 
gradual dilatation the surgeon must be thoroughly conversant 
with all forms of urethral inflammation. 

The scope of this volume will not admit of the consideration of 
the treatment of strictures by internal and external urethrotomy, 
but, in a general way, it may be stated that undilatable stricture in 
the pendulous urethra requires internal urethrotomy, while those 
of the bulbous and membranous urethra require external urethrot- 
omy ; for full information concerning which the reader may con- 
sult my work entitled A Practical Treatise on Genito-urinary and 
Venereal Diseases and Syphilis. Philadelphia, 1900. 



CHAPTER XVIII. 

CHRONIC AFFECTIONS OF THE PROSTATE. 

By far the most frequent cause of sexual weakness and impo- 
tence is chronic inflammation of the prostate gland. This morbid 
condition is produced by various causes, the most frequent prob- 
ably being acute and chronic gonorrhoea, the next in order being 
masturbation and sexual excesses, while in a less number of cases 
traumatisms, such as damage to the posterior urethra by sounds, 
lithotrites, dilators, endoscopes, and very caustic deep injections 
are the starting-points of the trouble. 

It is necessary to clearly understand the far-reaching effects 
which acute and chronic gonorrhoea often exert upon the pros- 
tate, since such knowledge renders clear the etiology of many 
cases which might otherwise seem very obscure. 

GONORRHEAL CONGESTION OF THE PROSTATE. 

The most common form of inflammation of the prostate in the 
course of gonorrhoea is congestion of more or less severity. This 
condition occurs with, and is dependent upon, acute posterior 
urethritis. In the latter condition the submucous connective 
tissue is the seat of an acute phlegmasia, and as a result the sub- 
stance of the prostate becomes hyperseniic. With this further 
extension of the gonorrhoeal process the patient has still other 
symptoms besides those of the posterior urethritis. He complains 
of a sensation of dull weight and pressure in the perineum deep in 
the pelvis, and an uneasy sense of fulness in the rectum or anus. 
In severe cases rectal tenesmus may add to the patient's discomfort. 
The vesical tenesmus may be increased, and often in defecation 
the patient experiences severe pain in the prostate when the fecal 
mass passes under it. When there is much swelling the stools are 
small and ribbon-shaped. Rectal examination reveals a swollen 



230 SEXUAL DISORDERS OF THE MALE AND FEMALE 

organ, broader than normal from side to side, and bulging consid- 
erably into the rectum. The finger-tip reveals the fact that the 
part is hot and decidedly painful, and on its withdrawal vesical 
and rectal tenesmus frequently ensues. In many cases pollutions 
are a distressing symptom. The swollen state of the prostate 
generally causes dysuria, or even such a condition of retention 
that it is necessary to remove the urine with a catheter. 

In the great majority of cases this congestion is temporary. It 
may last a few days or two or three weeks ; usually, however, 
resolution takes place in about ten days. With the decline of the 
posterior urethritis the swelling and tenderness usually subside. 
In some cases the involution of this congested condition of the 
prostate occurs suddenly and unexpectedly a few days after its 
onset. 

Fig. 65. 




Kemp's double current hard-rubber rectal irrigator. 

Congestion of the prostate may be due to violence from sounds, 
catheters, lithotrity instruments, to the irritation of a stone in the 
bladder or of a fragment of stone, or of small stones impacted in 
its mucous membrane, and to stricture. It is not very probable, 
as claimed by some, that injections used by patients in the ante- 
rior urethra cause congestion of the prostate. 

Long-continued masturbation is also a frequent cause of chronic 
congestion of the prostate. 

Treatment. In the acute stage of congestion of the prostate, 
rest in bed and antiphlogistic treatment are required. 

When the congestion becomes chronic the condition may be 
discovered by the finger-tip in the rectum, which finds the organ 
soft and boggy or swollen and tense. At this time gentle massage 



CHRONIC AFFECTIONS OF THE PROSTATE. 231 

may do much good, but it may cause distress, and then it should 
be stopped. Warm, hot, or cold saline solution irrigations of the 
rectum may be given once or twice a day by means of Kemp's 
prostatic cooler (Fig. 65), and are often of much benefit. This 
useful instrument is made of both hard and soft rubber, so the 
surgeon may have his choice. In chronic congestion of the pros- 
tate, mercurial, ichthyol, or iodide of potassium suppositories may 
be used (vide infra). In all cases the condition of the urethra 
should be ascertained, and if diseased it should be treated. 

CHRONIC INFLAMMATION OF THE VERUMONTANUM 
AND PROSTATIC URETHRA. 

This form of chronic prostatitis is not very uncommon, and is 
found, as a rule, in young men from about eighteen to twenty-five 
years of age. The underlying causes are either prolonged mas- 
turbation, or, rather less frequently, chronic posterior urethritis, or 
both may be factors. Patients thus afflicted may enjoy tolerably 
good health or they may be anaemic or even neurasthenic. (See 
section on Chronic Posterior Urethritis, with which this condition 
is sometimes combined.) 

The first symptoms pointing to this prostatic disorder are refer- 
able to the sexual system. In those patients who indulge in 
coitus it is first noticed that they suffer from premature ejaculations. 
Erections may be firm and desire may be great, but the sexual 
act is aborted. Then, as time goes on, the erections become less 
vigorous and the ejaculations are weak and dribbling. Unless 
relieved such patients become impotent. Besides these symptoms 
nocturnal pollutions may trouble the patient, who may also observe 
the escape of mucus from the urethra after urination or defecation. 
In some cases a sense of weakness and depression follows the sup- 
posed loss of semen. All these symptoms may be observed in 
those whose trouble originated in masturbation. 

When the emission or ejaculate is examined under the micro- 
scope it is found to consist of mucin and granular phosphates, as 
a rule (see Fig. 66), but in some quite chronic cases puny and 



232 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

dead spermatozoa may be seen in the fluid, together with cuboidal 
cells, pus, and perhaps oxalate of lime. 

When the urine is examined, if posterior urethritis exists, the 
first few ounces will contain gonorrheal threads (see page 215 and 
Fig. 55), the second specimen will be clear, and iu some instances 
the third specimen will have a decidedly milky appearance, due 
to the mucus and granular phosphates which have been expressed 
by the contraction of the prostate. If, however, after the second 

Fig. 66. 




Granular phosphates. 



cylinder has been filled with clear urine and some of the residuum 
is still left in the bladder, massage of the prostate will cause a 
more or less copious flow (one-half to two or three drachms) of a 
mucus which may be thin and milky or as thick as condensed 
milk. This secretion may escape from the meatus or it may be 
voided with the urine. In any event, in this form of prostatitis 
(and the same is seen in other forms) the dominating component 
parts will be found to be mucus and granular phosphates. (See 
Fig. 66.) And it may be here stated that this combination is the 



CHRONIC AFFECTIONS OF THE PROSTATE. 233 

one which, with more or less admixture of other crystals and of 
tissue-elements, will be found throughout the course of the various 
forms of prostatitis yet to be considered. Sometimes mucus 
escapes which is not mixed with phosphates, but this is not of fre- 
quent occurrence. It is most important, therefore, that the sur- 
geon should become thoroughly familiar with this muco-phosphatic 
secretion and with the urine which is so commonly voided by these 
patients. The urine is usually of low specific gravity (1004 to 
1010), of moderately neutral, alkaline, or not very acid reaction. 
Its color is of a pale straw tint, and it is usually voided in con- 
siderable quantities. Much familiarity with these cases will enable 
the surgeon (if he were so disposed) to make a diagnosis simply 
from inspection and microscopic examination of the urine. As 
has already been said, the dominating feature of the abnormal 
discharge is the combination of mucus and granular phosphates. 

These patients sooner or later complain of frequent urination ; 
in some it occurs at night, in others in the daytime, and in still 
others both by day and by night. Some patients complain of 
pain in the passage of the urine as if it scalded, or as if a hot iron 
were in the canal, and it is not uncommon for these patients to 
experience a dull pain in the glans penis at the end of urination. 
Some patients have a sensation as if their urine escaped, but 
examination of the penis shows that it is dry. 

Endoscopic examination of these cases should not, as a rule, be 
made, since they are usually very painful, and the conditions 
which they reveal can be determined by other and less severe 
means. The facts already in our possession, derived from the 
endoscopic study of the prostatic urethra in these cases, show very 
clearly that the whole canal is very red and swollen, and this is 
observed particularly in the verumontanum and the adjacent sur- 
faces. 

Examination of these cases with the bougie a boule shows the 
same state of affairs. As the bulb enters the prostatic urethra the 
already apprehensive patient may experience a severe and even 
stabbing pain, which causes him to cry out, particularly as it 
glides over the verumontanum. In many instances, on the with- 



234 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

dra will of the instrument a little blood will be seen on the bulb or 
at the meatus. 

In some cases when the steel sound is introduced there may be 
some impediment at the bulb, due to spasm of the compressor 
urethral muscle. This, however, is soon and painlessly overcome, 
and then the tip of the instrument passes into the prostatic ure- 
thra, where it may cause at first as much pain as the bulb does. 
In some cases a powerful spasm of the prostate may be induced, 
by which the sound is thrown out of the urethra, or an orgasm 
may occur, and the same result may be produced. As a rule, the 
great sensitiveness of the deep urethra disappears under careful 
treatment, and the introduction of the sound then comes to be a 
source of comfort. 

Now, when these cases are further examined by means of the 
finger in the rectum much important information may be obtained. 
On careful palpation of the prostate with the finger-tip the sur- 
geon may find no enlargement or perceptible change ; indeed, no 
pain may be produced unless deep pressure be made. If, how- 
ever, the sound is left in the urethra, and then pressure by the 
finger-tip in the rectum is made, the patient may experience pain, 
and even cry out in agony. 

Now, by this study of the symptomatology, by the considera- 
tion of the antecedents and age of the patient, and by the results of 
instrumental and urinary examination, we are warranted in draw- 
ing the conclusion which has been largely fortified by post-mortem 
examinations, that such patients are suffering from exudative 
catarrhal inflammation of the mucous membrane of the prostatic 
urethra, and that the verumontanum, with its numerous contained 
mucous tubules and copious nerve- and blood-supply, is the focus 
of that process. This condition, which is now generally vaguely 
alluded to as spermatorrhoea, to my mind is a distinct morbid 
entity, and it may exist, I am positive, without any extension or 
involvement of the environing prostatic substance or of the sexual 
parts beyond. Careful studies of post-mortem subjects have 
clearly proved this condition, which can readily be demonstrated 
in life if the surgeon has sufficient experience and skill. 



CHRONIC AFFECTIONS OF THE PROSTATE. 235 

This affection, as it becomes very chronic, may lead to catar- 
rhal inflammation of all the gland-tubules, and then distinct en- 
largement of the organ can be readily made out. 

Prognosis. As a rule, these cases are quite promptly benefited 
by treatment, provided they will conform to the requirements of 
sexual hygiene. Sexual and alcoholic excesses prove great draw- 
backs to a cure and materially interfere with the treatment. 

In anaemic and neurasthenic subjects this form of prostatitis is 
sometimes very chronic, and the continuance of local inflamma- 
tion leads to the intensification of the general low condition. In 
many cases, however, brilliant results follow a carefully adapted 
method of treatment. 

Treatment. The treatment in the main is that advised for 
posterior urethritis. The health and morale of the patient should 
be improved as much as possible by all hygienic influences. In 
anaemic and neurasthenic cases iron, quinine, and strychnine are 
very beneficial, and they may be combined with coca extract. 
(See p. 103). 

This combination will be found useful in most cases of sexual 
disorder in which anaemia or neurasthenia coexists. 

But in all these cases the existence of the local inflammation 
deleteriously reacts on the sexual centre and the general nervous 
system, and it is of prime importance to cure that. To this end 
the careful introduction of a goodly sized (20 to 30 French scale) 
steel sound (chilled in ice-water), two or three times a week, and 
its retention in the urethra for three or four minutes, may be very 
beneficial ; or, should the surgeon prefer, he may use the now- 
nearly-out-of-date psychrophor. 1 (See Fig. 67.) 

Instillations and irrigations of nitrate of silver, permanganate 

1 " A double-current catheter without eyes, the two canals communicating near 
the point of the instrument. It is introduced into the urethra until its point 
has passed the pars prostatica, and it is then attached by rubber tubing to a 
reservoir containing water of the desired temperature. On turning the stopcock, 
the water flows into one canal and out through the other. In this way the caput 
gallinaginis and the entire mucous membrane are exposed to the mechanical 
action of pressure and the sedative action of cold." 



236 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

of potassium, or of alum and sulphate of zinc, may be used in 
most cases with much benefit. 

Good results often follow the use of the cupped sound of a 
calibre of 24 to 30 French scale, which may be introduced once or 
twice a week. (See Fig. 68.) Into the little depressions on the 
curved part of the sound small portions of an ointment composed 
of nitrate of silver and vaseline or simple cerate (5ss-5j to §j) may 
be placed, which, when the instrument is in the urethra, will melt 
and soak into the morbid tissues. 



Fig. 67. 




Psychrophor. 
Fig. 




Cupped sound. 

Constipation should be avoided, and coffee, liquors, asparagus, 
and spiced dishes should not be indulged in. 

Bromide of potassium, belladonna, and hyoscyamus may be used 
with caution to meet the condition of erethism when it arises. 

Prostatic massage is not, as a rule, indicated in these cases. 



CHRONIC AFFECTIONS OF TEE PROSTATE. 237 

CHRONIC CATARRHAL INFLAMMATION OF THE 
PROSTATE. 

This condition is not very uncommon, and in order to fully 
understand it it is necessary to be familiar with the general and 
minute anatomy of the prostate. (See page 38.) 

In some cases gonorrhoea and in others masturbation is the 
primary cause. The essential lesions are, first, a round-cell 
infiltration and hyperemia in the connective tissue around the 
gland-tubules ; and, second, simple catarrh of the lining mem- 
brane of the gland-tubules. This periglandular inflammation is 
usually continuous with that of the mucous membrane of the pro- 
static urethra ; but in some cases this latter condition may not co- 
exist, or it may be only an insignificant feature. 

Histological investigations have shown that in some cases of 
inflammation of the prostatic urethra only the ducts of the glands 
have been involved, consequently the parenchyma of the prostate 
escaped. It has also been shown that one or more groups of 
gland-tubules may be attacked in an irregularly scattered manner, 
either on one side or both, and that symmetrical involvement may 
not occur in one or in both halves of the prostate. The inflam- 
matory process may invade in an irregular manner several groups 
of glands on one or both sides of the organ, and there may be 
scattered here and there groups which remain unaffected. This 
peculiarity of the prostatic inflammation is due to the anatomical 
arrangement of the tubules, which, in passing into the depths of 
the organ, remain separate from one another. Thus it happens 
that the inflammatory process, when attacking a tubule or a group 
of tubules, runs down them to their blind ends, and thus limits 
itself and shows no tendency to invade the peripheral parts. In 
some cases the whole mass of gland-tubules may be attached. 
This knowledge will explain to us why in some cases the whole 
gland is swollen, why in others its surface feels nodulated and 
lumpy, and in still others present the sensation as if many good- 
sized shot were deeply embedded in the capsule of the prostate. 
In the first case the glands of the whole organ are quite uniformly 



238 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

attacked ; in the second case groups of glands are swollen and cause 
nodulations and lumps on its external surface ; and in the third 
case individual glands scattered irregularly over the organ are the 
seat of the inflammation which by its limited swelling gives the 
finger the sensation as if shot were seated in the tissues. 

Such are the anatomo-pathological facts and the resulting con- 
ditions which are revealed to the surgeon in examining cases of 
chronic catarrh of the prostate. 

The pathological conditions here mentioned may lead to various 
secondary morbid states, which will be brought out later on. 

Chronic prostatitis is observed in the period between puberty 
and middle age, but mostly between twenty and forty-five years. 
It occurs in all classes, in the poor and in the rich. Though the 
morbid conditions in the prostate are nearly the same in all cases, 
the symptoms presented vary considerably in different cases. 
This marked variation in the symptoms allows the classification 
into certain forms of the disease, the description of which will 
lead to recognition. 

Temperament, habits, and age have much to do with the diver- 
sity of the symptoms ; but in the chronic course of the disease 
certain secondary conditions are developed and certain complica- 
tions may be induced which also give rise to marked symptoms. 
Thus in many cases the symptom-complex is very striking. 

Some patients suffering from chronic prostatitis experience little 
trouble, and they give themselves scarcely any concern about the 
matter. Other patients may be troubled more or less in mind, 
but their health is not seriously affected, while still others become 
weak and nervous, and even truly neurasthenic. In some cases 
prostatitis causes no symptoms, or if present they are unrecog- 
nized until some failure of the health occurs from dyspepsia, 
mental worry, grip, or acute adynamic diseases. After catching 
cold, standing for a long time in the cold, or sitting on cold stones, 
the symptoms of chronic prostatitis have first shown themselves. 
There is clear evidence at hand that chronic prostatitis has lasted 
many years (five to fifteen) without having caused appreciable 
symptoms, and its existence was unsuspected by the patient. 



CHRONIC AFFECTIONS OF THE PROSTATE. 239 

Chronic prostatitis runs a long and irregular course, with short 
or long periods of exacerbation and of remission, in which the 
symptoms are insignificant, mild, and bearable. 

My experience and study have convinced me that the most cor- 
rect and satisfactory division of chronic prostatitis is, first, that 
form which is observed in patients between the twentieth and 
thirtieth years, or thereabouts, and, second, a more advanced form, 
which is seen mostly in patients beyond the thirtieth year. This 
division is not at all arbitrary, but is based upon certain quite 
uniform type-forms. 

Catarrhal Prostatitis in Young Subjects. 

The symptoms which cause patients of this class to seek relief 
at the hands of the surgeon may be arranged, for clearness of 
description, into three categories : First, those of patients who com- 
plain of uneasiness in the prostate and perineum and rectum ; 
second, those of patients who after defecation, urination, and 
severe muscular exertion notice a mucous discharge from the 
penis ; and, third, those of patients who complain of some form 
of sexual weakness. 

In some of these cases there is coexistent inflammation of the 
verumontanum. (See previous section.) 

Patients who complain of uneasiness and pain in the prostate 
are mostly those who have masturbated immoderately, or whose 
trouble began in specific posterior urethritis. Very often the 
symptom is so slight that it causes no annoyance or impairment 
of health. In some cases the worry and fret lead to anaemia, and 
in severe cases neurasthenia may be induced. The pain or un- 
easiness may be continuous or spasmodic, or it may only be felt 
after defecation, urination, and severe bodily exertion. 

Examination of the prostate by means of the finger-tip in the 
rectum shows various conditions, as follows : the whole organ 
may be a little or much swollen in all directions, or but one-half 
of it (and usually it is the left one) may be the seat of the con- 
gestive infiltration. Moderate or severe pain may be produced 



240 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

by pressure, or such may be the extreme sensitiveness of the gland 
that the patient will not allow it to be touched. Then, again, 
one lump or many of them may be felt — in most cases, I think, 
limited to one lobe, and in a smaller number found irregularly 
scattered in both lobes. These lumps are more or less painful. 
And, lastly, there may be found scattered over the whole prostate 
half-pea-sized or large-shot-sized prominences, of which there may 
be two or three or even a goodly number seated on one or both 

Fig. 69. 




Granular phosphates, oxalate of lime, spermatozoa, and pus-cells. 



lobes. The discovery of these morbid foci clearly warrants the 
diagnosis of chronic prostatitis. (In some cases the existence of 
tuberculosis may be suspected.) In any of the foregoing condi- 
tions massage of the prostate will cause certain abnormal mucoid 
secretions to escape from the meatus or to appear in the urine. 
These secretions are as follows : 1, that of chronic posterior ure- 
thritis (see Fig. 55) ; 2, a clear, viscid mucus ; 3, mucus and 
cylindrical prostatic epithelium (see Fig. 21) ; 4, mucus (thin or 
thick and viscid) and granular phosphates (this is the secretion 



CHRONIC AFFECTIONS OF THE PROSTATE. 241 

most commonly found) ; 5, mucus, granular phosphates, and cylin- 
drical epithelium (these are usually found in very recent cases) ; 
6, mucus, granular phosphates, dead and puny spermatozoa, and 
oxalate of lime (see Fig. 69) ; and, 7, mucus, granular phosphates 
with either triple phosphates (see Fig. 70) or crystalline phosphate 
of lime (see Fig. 71). In any of these secretions there may be 
at some time spermatozoa and pus present. 

The essential secretion of all chronic catarrhal prostatic inflam- 
mation is mucus in which there is a greater or less admixture of 
granular phosphates. 1 (See Fig. 66.) This secretion in excess 
attests the activity of the cylindrical epithelial cells lining the 
tubules, whose function in health is to secrete a thin milky fluid, 
together with the granular phosphates, which constitute the true 
phosphatic fluid which plays such an important role in the produc- 
tion of pure, fertile semen. (See p. 188.) In disease this normal 
process becomes exaggerated, and as a result we see when examin- 
ing cases of catarrhal prostatitis the clear viscid mucus, the milky 
secretion, and that which looks as it escapes from the meatus like 

1 In many cases the quantity of these salts in the urine, the ejaculate, or in the 
expressed secretion is not very large ; but in some it is surprising to see the very 
large amount of these granular salts which have been voided in the third speci- 
men of urine, or have been pressed out by prostatic massage. In one instance, 
after urination into two cylinders, in neither of which any granular phosphates 
were present, the balance of clear urine was drawn off by means of a small soft- 
rubber catheter, and four ounces of sterile water were thrown into the bladder. 
Then, the prostate having been well massaged, the patient expelled the injected 
water, together with the expressed mucus. After settling, this liquid showed a 
thick layer of granular phosphates, and when the whole were thrown upon a 
filter, and the salts were dried and collected, it was found that they weighed one 
hundred and fifteen grains. These facts, which can be verified by anyone who 
will carefully examine his cases, very clearly show that very many cases which 
are now classed under the title phosphaturia, and in which it is supposed that 
some disturbance of the nervous system causes the excess of phosphates, are 
really instances of chronic catarrhal prostatitis. These observations also very 
clearly show that those authors who consider many sexual disorders to be sensory 
and motor neuroses, due to some undefined nervous condition in which phos- 
phates are found in excess in the urine, have confounded cause with effect. The 
truth is, the diseased prostate produces the phosphatic excess, and, acting on a 
central focus of irritation, it, in all probability, reacts locally on the cord, and 
through it upon the whole nervous system. 

16 



242 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

Fig. 70. 



Triple 




3, granular phosphates, and spermatozoa. 
Fig. 71. 




Crystals of phosphate of lime and granular phosphates. 



CHRONIC AFFECTIONS OF THE PROSTATE. 243 

a wormy mass of condensed milk. When the prostatic inflamma- 
tion becomes still more chronic we find the other admixtures 
which have just been enumerated. It may here be mentioned 
and emphasized that in most cases of chronic catarrhal prostatitis 
in young subjects the ejaculation in masturbation is composed 
mostly of the above-mentioned abnormal prostatic secretion, with 
or without the other salts or spermatozoa. Further, it is well to 
bear in mind that the so-called nocturnal pollutions in these cases, 
the defecation and urination ejaculate, and the secretion which 
escapes from the urethra after hard work, are all wholly or nearly 
composed of mucus and granular phosphates. In some cases, 
owing to causes to be mentioned a little later, some spermatozoa 
may be found in the ejaculate. With this statement of facts held 
well in mind (which I have verified in clinical observations and by 
microscopic studies scores of times), the vague conception of that 
old-time bugbear of medicine — namely, spermatorrhoea — really 
becomes an enlightened subject. 

In some of these cases there is increased frequency of urination 
during the day, and perhaps during the night, and there may be 
more or less uneasiness or pain at the end of the act. In some 
cases at the end of urination there is marked tenesmus, which 
may radiate to the pelvis, rectum, and anus, and cause much dis- 
tress of mind and suffering. These patients, besides uttering their 
complaints as to prostatic pain and soreness, often become much 
worried and nervous about their pollutions, which they think will 
render them permanently weak. Many of them sooner or later 
present evidences of declining sexual power. 

Unless cured by proper treatment these patients continue in an 
unsatisfactory state for months and years. Some may appear 
ruddy and healthy, even though they suffer somewhat, and 
worry ; others become decidedly nervous and anaemic, while not 
a few really become neurasthenic. 

In proportion as the mental and physical reaction is severe, so is 
the case unpromising as to ultimate relief. In general, with the 
improvement in the urethral and prostatic trouble which proper 
treatment brings about, the mental and physical condition improves. 



244 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

Many young men suffering from chronic catarrhal prostatitis 
make no complaint of symptoms which point to the prostate as 
the source of their trouble, but lay much stress upon their so- 
called loss of semen after defecation and urination and bodily 
exercise, and by nocturnal pollutions. In these patients, as a 
rule, we find by rectal examination all the tangible conditions of 
the prostate already mentioned, and microscopic examination of 
their urine, of their ejaculates, or of the expressed secretion of 
the prostate will reveal the appearances detailed in the preceding 
pages. 

This class of patients usually become very nervous and excited, 
and from anaemia rapidly pass into a neurasthenic condition, and 
complain of an infinitude of morbid symptoms. They become 
sexually weak, while at the same time they are abnormally sex- 
ually excited, and the result is sometimes very depressing and 
discouraging. In many instances great harm results to these 
patients by their persistence in masturbation, futile attempts at 
coitus, and dalliance with women. The result in many cases is 
physical and mental exhaustion. 

A certain number of patients suffering from this form of pros- 
tatic disorder seek relief for their sexual weakness, which is the 
dominating symptom in their minds. In some cases erections are 
normal, but coitus after prolonged effort does not result in ejacu- 
lation. In other cases the act is performed in a weakly and un- 
satisfactory manner, and ejaculation is not attended with much, if 
any, sensation, and it collapses in feeble dribbling. Then, again, 
some patients complain of moderate erections and premature 
ejaculations, while in some erections no longer occur. In many 
of the cases thus summarized there is escape of morbid mucus 
either in nightly pollutions or after urination or defecation. Many 
of these patients are weak or anaemic, the majority of them are 
mentally much worried, and some of them are decidedly neuras- 
thenic. Unless relieved by proper treatment, these patients go 
from bad to worse. The essential point to be remembered in all 
of them is the necessity of the cure of the focus of the trouble in 
the prostate. 



CHRONIC AFFECTIONS OF THE PROSTATE. 245 

As catarrhal prostatitis becomes chronic in some cases the 
morbid process creeps up the ejaculatory ducts and involves the 
mucous membrane and that of the ampullae and of the seminal 
vesicles. The direct result of this extension is a more or less 
severe catarrhal condition of these parts. But the most striking 
effect produced is a condition of flabbiness of the outlet ducts of 
the ampullae and of the seminal vesicles and the development of 
more or less patulousness in the not very strong muscular fibres 
of the ejaculatory ducts. The process which really takes place in 
all these parts which normally safeguard the retention of the semen 
and prevent its escape is one of weakness and of incompetence, 
which allows the secretion to escape under various mechanical con- 
ditions (abdominal pressure, defecation, particularly with firm 
fecal bolus, and urination). When, therefore, chronic prostatitis 
is present with this, as we may term it, seminal incontinence, the 
abnormal ejaculate is composed of prostatic mucus and some of 
the secretion of the ampullae and seminal vesicles. As a rule, the 
amount of this fluid lost at any time by these patients is very 
small. The loss of this secretion per se is not the cause, of the 
deterioration of the health of the patient, as is so generally 
believed. The real morbid factors are the local lesions and the 
resulting mental unbalance and general depression of the economy. 

Catarrhal Prostatitis in Older Subjects. 

There is no uniformity in the clinical history of the cases of 
chronic prostatitis in patients beyond the thirtieth year. In some 
cases the symptoms are few and not well marked ; in others they 
are more pronounced, while in a few so striking is the symptom- 
complex that prostatic inflammation at once suggests itself to the 
mind of the surgeon. In these older patients we do not have to 
listen to so much persistence in the recital of their troubles con- 
cerning sexual discharges and the multifarious symptoms of sexual 
neurasthenia as we do in younger subjects. Older patients may 
become anaemic, and even more or less neurasthenic, but they 
rarely reach the deplorable condition so often seen in young sub- 



246 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

jects. The older patients, as a rule, have started in sexual life 
with their organs in a healthy condition, and disease has set in 
later. In the younger subjects the integrity of their sexual organs 
was much impaired and damaged before and at puberty. 

Fig. 72. 




-V/»t 



>\ 







Showing prostate of a man in which senile changes are beginning to develop. 
This section was made through the posterior portion of the prostate. Here the 
ducts run forward, and they therefore appear in cross-section in the drawing. 
The lobulation apparent in the prostate of the young subject (see Fig. 7) is no 
longer distinct, owing to the development of fibrous and muscular tissue. Vol- 
untary muscle-fibres are prominently developed on the superior surface of the 
organ. In the verumontanum the left ejaculatory duct is seen opening centrally 
into the prostatic sinus. The right ejaculatory duct shows as yet no communica- 
tion with the prostatic sinus, but opens at a point further forward. (Drawn from 
the Edinger projection apparatus ; much magnified. ) 



Examination of the prostate by means of the finger in the rec- 
tum of these older patients gives somewhat different results from 
those found in young subjects. The whole prostate may be sym- 
metrically enlarged to as much as double its normal size ; only 
one-half of it may be more or less enlarged, or we may only find 
one or more well-defined large or small lumps, which, in excep- 



CHRONIC AFFECTIONS OF THE PROSTATE. 247 

tional cases, may have a soft structure. But in these cases, as a 
rule, there is evidence of firm structure, even approaching true 
hardness, and the finger-tip gives the surgeon the impression that 
marked cell-proliferation must have occurred in the organ. This 
clinical fact is clearly explained by the results of histological 
studies, which have shown that with the chronicity of the inflam- 
matory process new connective tissue has been developed around 
the tubules to such an extent as to produce a semi-sclerotic condi- 
tion of the gland. For a long time this new cell-growth causes 
the decided increase in the size of the gland which has been men- 
tioned, but later on a cirrhotic condition sets in, by which the size 
of the gland is materially decreased, even to the point of atrophy. 
(See Fig. 72.) 

It is sometimes observed that when one lobe of the prostate is 
attacked there is pain in the corresponding side of the rectum. 
This condition is also found in some cases of unilateral seminal 
vesiculitis. In still other cases we find an enlarged, somewhat 
eburnated organ, which is the seat of firm, half -pea-sized nodula- 
tions. 

With the continuance of the chronic catarrhal process the lumen 
of the tubes in many cases becomes more or less plugged up by 
phosphatic concretions, by desiccated masses of old, cast-off epi- 
thelial cells, and by amyloid bodies. Some of. these abnormal 
products may be sometimes observed in younger patients. 

Catarrhal prostatitis in older subjects not infrequently gives rise 
to very poorly marked symptoms. Some patients complain of 
uneasiness, as they term it, at the neck of the bladder, and others 
speak of more or less deep pelvic pain, which they think is in 
some manner connected with the rectum. In some cases the pain 
is felt on standing up, in others after muscular exertion, bicycle 
exercise, and horseback-riding, while in still others it is felt when 
in certain positions on sitting down, particularly on the edge of a 
chair. In some cases the uneasiness is also felt in the perineum 
and anus, and in other cases on one side of the body corresponding 
to the side of the prostate involved. In some cases pain in one 
hip-joint is complained of. In many of these cases there is fre- 



248 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

quency of urination, and in some there is pain in the glans penis 
at the end of the act. Most patients thus affected have some form 
of sexual weakness, which is either mild or pronounced, and some 
have abnormal mucoid discharges. 

The uneasiness and pain in the prostate may be more or less 
continuous, or mildly paroxysmal, or it may be rendered worse 
when the bladder is much distended and when constipation or 
diarrhoea is present, in which instances there may be decided 
tenesmus. 

Some of these patients speak of a vague feeling of numbness 
deep in the pelvis and in the prostate, and this feeling may also 
exist in the perineum. In these cases there may not be much dis- 
turbance of the health, though some patients become ansemic and 
worried. 

In marked contrast with the foregoing mild order of cases are 
those in which the symptoms are numerous, severe, and complex. 
In these cases there is more or less ill-health, and in some neuras- 
thenia. Such patients first complain of vague and sometimes fugi- 
tive pains in the back, loins, and pelvis. Inquiry then will 
usually bring out the statement that there is increased frequency 
of urination, and perhaps pain in the prostate and the glans at the 
end of the act, and that their sexual capacity is rather weak. 
Sometimes it will be found that one lobe of the prostate has been 
involved, and that the pain in the glans penis is referred by the 
patient to the corresponding side of the prostate gland. There 
may be present either sexual apathy or erethism. These patients 
sometimes notice the escape of morbid mucus, which may be thin 
and milky, or clear and very viscid (like liquid glue), or it may 
look like condensed milk or very thick glue. (See Fig. 73.) 
When in these conditions the ampullations and the seminal vesi- 
cles are also involved, some of their secretion may escape and 
become mixed with the prostatic mucus, in which event the secre- 
tion is usually of a yellowish-brown color. It will generally be 
found, in these older patients, that when the secretion comes from 
the prostate it is white or slightly turbid, like liquid glue, or 
grumous, but that when it comes from the seminal vesicles or 



CHRONIC AFFECTIONS OF THE PROSTATE. 



249 



ampullations it is of a yellowish-brown, or, exceptionally, of a 
dark-brown tint. The diagnostic indications which are observed 
by inspection of the color of the morbid mucus from the deep 
seminal parts can readily be verified by microscopic examination. 
The urine of these patients is usually of rather low specific 
gravity (1008 to 1013), of pale color, of feeble acidity, or perhaps 
it may be quite constantly alkaline. It is, as a rule, rather opaque 
and sometimes of decidedly milky hue, and upon its surface very 

Fig. 73. 




Secretion of chronic prostatitis, showing granular phosphates, degenerated 
cylindrical epithelial cells, and pus. 

frequently an iridescent pellicle forms. The phosphatic salts, 
being in great excess, sometimes appear like a sheen of little 
whitish glistening particles. On standing in the cylinder or urine- 
glass the sediment first collects throughout the specimen in little 
cloudy tufts, somewhat resembling water which is slowly freezing. 
Then, in a short time, the sediment sinks to the bottom of the 
glass and forms a tolerably thick mass, which has a flocculent, 
grayish-white appearance, very different from that presented by 
pus. 



250 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

In some of these cases of chronic prostatitis in older subjects 
(and it is sometimes seen in younger patients) a peculiar form of 
emission or ejaculate is observed which needs description. Such 
patients more or less frequently see, after urination or defecation 
or hard work, a thick ropy, whitish mass escape from the urethra 
which looks like plaster-of-Paris mixed with water. In some 
cases the escape of this stuff is unattended with any unpleasant 
symptom, but in others there is a sensation of sickness at the 
stomach and great weakness during and for a time after its 
passage. In some cases there is a scalding sensation in the whole 
course of the urethra, beginning at the prostate, and such may be 
the patient's suffering that he becomes pallid, is thrown into a cold 
sweat, and he may be on the point of fainting. This discharge 
may occur at short or quite long intervals, and the fear of its 
occurrence creates in the minds of some patients great apprehen- 
sion and fear. 

Microscopic examination of these abnormal discharges shows 
that they are composed of mucus and granular phosphates, 
together with (in some instances) triple phosphates and crystalline 
phosphate of lime. (See Figs. 69, 70, and 71.) There may also 
be other components, such as pus-cells, prostatic epithelium (see 
Fig. 73), and some spermatozoa. Many of these patients think 
that they are suffering from a particularly severe form of sperma- 
torrhoea, and they may become much depressed in mind and even 
mildly neurasthenic. 

In some cases of chronic prostatitis in older subjects there is at 
one time hyperesthesia of the prostatic urethra, in which event 
there may be much sexual erethism, some frequency of urination, 
and more or less pain in the whole act. Ejaculation may be some- 
what premature, but it is usually attended with unpleasant, even 
painful, sensations, which may soon cease or which may last for 
hours or for a day or two. In some of these cases of erethism 
the penis is often in a semi-erect condition, and prostatic mucus 
flows from the urethra at times. 

The course of this hypersensitiveness of the prostate and pros- 
tatic urethra, when uninfluenced by treatment, is much prolonged, 



CHRONIC AFFECTIONS OF THE PROSTATE. 251 

and it may be uneventful or be attended by marked exacerbations. 
As time elapses the erethism gradually ceases, and in some cases 
it is followed by very decided anaesthesia in the parts, which may 
extend throughout the course of the urethra, and in a mild form 
involve the bladder. There may also be partial insensitiveness 
of the testes, scrotum, perineum, and upper portions of the thighs. 
In some rather rare cases of prostatitis with involvement of the 
ampullae and of the seminal vesicles I have seen this queer asso- 
ciation of these numb sensations. In this condition there may be 
interference with the function of urination and with coitus. Such 
patients state that sometimes they are not aware of the fact that 
the bladder is full, and when they attempt its evacuation, though 
the stream may be full in size, it is feeble and more or less halt- 
ing. Then, again, erections may be normal, but ejaculation is 
feeble, and the sexual act may suddenly collapse. 

By massage of the prostate thus affected we cause the escape of 
several forms of mucus which present somewhat different features 
from one another. This expressed secretion may consist of mucus 
or mucus and glandular phosphates, perhaps combined with triple 
phosphates and phosphate of lime, or it may contain degenerated 
prostatic epithelium, pus, spermatozoa, phosphatic concretions, 
amyloid bodies, and cylindrical casts of the prostatic tube-glands. 

In these older cases it is very common to see (as we sometimes 
do in the secretion of younger subjects) the granular phosphates 
arranged in the shape of regular cylinders, which are straight or 
more or less curved. (See Figs. 66 and 73.) These cylinders 
are formed in the tubules by the functional overactivity of the 
prostatic epithelial cells. Phosphate of lime is formed in excess 
at the same time that a thick, gluey mucus is proliferated. These 
two component parts, remaining for a time in the tubules, become 
amalgamated, and the muco-phosphatic cylinders are the result. 
These granular phosphates also give rise in the prostate to certain 
little oval or round bodies, to which the term prostatic concretions 
should, I think, be applied. They are small masses, composed 
of the same structures as the cylinders — namely, mucus and gran- 
ular phosphates. They are variously colored ; some are yellow 



252 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

(and may be mistaken for urates, but chemical analysis will prove 
their true nature), or they may be moderately red or of a deep 
purple tint. (See Plate VIII.) These little bodies remain in an 
indolent manner in the tubules (and undoubtedly cause pain and 
uneasiness), and they may excite more or less hemorrhage, in 
which event they become colored to a greater or less extent. 
These phosphatic concretions may become the nuclei of calculi. 
In some specimens of urine and of expressed prostatic secretion 
we find very firm threads, which are of a yellowish, a brown, or 
a purple color, and on examination are found to consist of gran- 
ular phosphates, mucus, and altered blood-cells. These threads 
are undoubtedly the initial forms of the little colored phosphatic 
concretions. 

In some exceptional cases, particularly of old men, we find well- 
marked hyaline cylinders. 

These hyaline cylinders, which look like large hyaline renal 
casts, are undoubtedly due to the inflammatory exudation which 
takes place in the depth of the gland-tubules. They are some- 
times quite long, wavy, of irregular contour, and in some cases 
somewhat bulbous on one end. They are not of constant occur- 
rence, and are usually found in cases in which the painful symp- 
toms are well marked. 

Amyloid bodies are not, as stated in the books, of frequent 
occurrence. They are seldom seen in the prostatic secretion of 
younger subjects,' and are rather exceptionally found in that of 
older patients. We cannot to-day state definitely what are their 
component parts, but they are in all probability composed of 
mucus, desiccated albuminous matter, intermingled with phos- 
phatic salts. These bodies present distinct and symmetrical stria- 
tions, which are very clearly shown in Plate IX., which also 
shows the structure and arrangement of the tubular prostatic 
glands. 

Small prostatic concretions resembling mustard seeds may be 
found in the ducts of many tube-glands, and they may cause any 
of the foregoing painful symptoms. These little round, brownish, 
shot-like masses are largely composed of mucus and lime salts. 



PLATE VIII. 




Concretions of Chronic Prostatitis. 



PLATE IX. 




Amyloid Bodies in the Prostatic Tubules 
Shown on Transverse Section. 



CHRONIC AFFECTIONS OF THE PROSTATE. 253 

Phospliatic calculi may exist in the ducts or in the tube-glands 
themselves, and produce painful symptoms. These calculi are 
composed of lime salts, sometimes in combination with oxalate of 
lime. They are oat-shaped or bean-shaped, though sometimes 
they are round. There may be one calculus, or there may be as 
many as a dozen, or several dozens, in one prostate. 

There can be no doubt that these various concretions just 
described act as foreign bodies, which, by plugging up, destroy 
the function of the tubules, and by their presence give rise to the 
uneasy sensations and pains complained of by these patients under 
varying conditions (sitting down, horseback and bicycle exercise, 
golf, urination, defecation, and copulation). 

Chronic prostatitis in older subjects, as in younger ones, may 
be complicated with chronic bulbous or posterior urethritis, and it 
is not infrequently coexistent with chronic inflammation of the 
ampullae and of the seminal vesicles. When these sacs at the 
base of the bladder are involved there may be the same seminal 
incontinence which is observed in young men. When this sem- 
inal vesicular condition exists we may find in the urine, in the 
expressed secretions, and in that which escapes after urination and 
defecation or severe exercise, the tissue-elements depicted in Figs. 
73 and 74. 

PROSTATORRH(EA. 

In some rare cases of chronic prostatitis the discharge is so copi- 
ous that the term prostatorrhoea has been applied to them. In 
these cases, when they are well marked, there seems to be a con- 
tinual production of mucus by the prostatic tubular glands ; there- 
fore, the most constant symptom is the escape from the meatus of 
a clear mucous fluid or of a mucus mixed with pus and perhaps a 
little blood. This mucous fluid may be scant in quantity, only a 
few drops appearing at the meatus in a day. It may also be 
more copious, and keep the end of the penis in a moist condition 
continuously, and in very pronounced cases the escape is so exces- 
sive that patients complain of a constant and annoying " drip- 
ping," which may wet and stain a large part of their shirt-flap or 



254 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

of the handkerchief, which they instinctively make use of under 
these circumstances. The escape of this discharge in large quan- 
tities occurs frequently during the act of defecation, particularly 
when the fecal bolus is hard and firm. In some cases the escape 
of the mucus causes a peculiar tickling feeling in the prostate and 
urethra, while in others it produces pleasurable voluptuous and 
lascivious sensations. Some patients claim that they can feel the 
escape of the fluid from the prostate into the urethra. In rather 
rare cases the escape of mucus, particularly after defecation, is 
attended with a sickening sensation of great faintness, which may 
last for several minutes. Many of these cases have been treated 
for spermatorrhoea. 

Although we have no pathological knowledge on the subject, it 
seems fair to assume that in prostatorrhoea there is such an atonic 
condition of the compressor urethra? muscle that it cannot prevent 
the escape of the fluid into the anterior urethra. The next most 
constant symptom is increased frequency in urination, which may 
be very excessive or only about twice as often as the normal 
desire. There may be decided uneasiness at the end of the act, 
and there may be a slight pain or decided scalding sensation, 
which passes from the prostate to the end of the penis. In many 
cases the stream is small and weak — a condition which seems to 
point to an atonic state of the detrusors. A sense of dulness and 
weight is often felt in the prostate and in the rectum, and pain 
and uneasy sensations are experienced in the perineum, thighs, 
and lumbosacral regions. 

Some patients suffer from chronic prostatorrhoea without be- 
coming much disturbed in mind by it. But there are others to 
whom this affection is little less than a calamity. They become 
exceedingly nervous about their trouble, even to the extent of 
being melancholy. They lose flesh, strength, and appetite ; they 
become irritable and incapable of mental and physical exertion. 
In fact, in some cases the whole morale of the man seems lost. 

In many cases of prostatorrhoea there is more or less disturb- 
ance in the sexual function. In some subjects it is morbidly 
exaggerated ; in others there is much desire, much erethism, many 



CHRONIC AFFECTIONS OF THE PROSTATE. 255 

erections, but very little is accomplished, owing to the precipitate 
ejaculations. In still other subjects there is little if any desire, 
even as a result of much excitement, and the penis and scrotum 
seem shrunken, cold, and lethargic. 

Rectal examintion of cases of prostatorrhoea reveals an enlarged 
organ, usually jutting more or less backward on the gut, and being 
decidedly broader than normal. Very often only one lobe or a 
portion of one may be involved. Sometimes it feels soft, and 
again it may seem decidedly indurated. There is commonly more 
or less tenderness, even severe pain, on pressure by the finger-tip. 
Urethral examination, even with a small and not stiff instrument, 
often causes a great outcry from pain when the tip passes through 
the prostatic urethra. 

Diagnosis. When the foregoing descriptions of clinical cases 
are borne in mind the suspicion of chronic prostatitis will force 
itself upon the surgeon's mind. Then rectal palpation will reveal 
the extent and severity of the local condition. At the same time 
the condition of the urine must be examined, and it, with any 
expressed mucus, must be carefully studied by means of the micro- 
scope. If these requirements are fulfilled, a very satisfactory 
estimate of the case can always be made. 

It may be well here to inform the beginner in the study of 
chronic prostatic disease that all the pictures of microscopic appear- 
ances already enumerated will not be found, as a rule, in one 
microscopic field. In the preparation of the specimens for these 
drawings I have carefully selected typical appearances offered by 
many microscopic fields, and have grouped them into one figure, 
which contains all the type-forms and some rather unusual ones. 
In every instance the endeavor has been made to delineate nature 
truthfully and exactly. 

Chronic prostatitis may be caused by tuberculosis, and by the 
exercise of care and skill a correct diagnosis can soon be positively 
made. The examination of the urine in these cases for the bacillus 
tuberculosis will in many true cases be unattended with the detec- 
tion of the micro-organism. It is absolutely necessary in these 
cases to examine preferably the expressed or the escaped prostatic 



256 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

secret ion after proper staining. Great care should be taken that 
the penis, and particularly the glans, be rendered absolutely sterile, 
since upon these parts the smegma bacillus lives and hibernates, 
and the detection of this inert microbe might lead the unwary 
examiner to mistake it for that deadly bacillus which causes tuber- 
culosis. 

But, in addition to the condition of the prostate, the surgeon 
must make himself familiar with that of the urethra, chiefly its 
bulbous and prostatic portions, and also of the state of the seminal 
vesicles and of the ampullations. In forming an estimate of a case 
it is well to bear in mind that in young individuals a more or 
less recent gonorrhoea may have existed, and that it is very com- 
mon to find the damage quite sharply limited to the deep urethra 
and prostate, and perhaps largely to that gland. It is exceptional 
to find seminal vesicular involvement in young subjects. In older 
individuals the prostate and the seminal vesicles and ampullations 
may be the seat of chronic inflammation, and this complicated con- 
dition can be clearly made out by rectal exploration and by micro- 
scopic study of the expressed secretions or of the urinary sediment. 

Prognosis. In very many uncomplicated cases of catarrhal 
prostatitis most satisfactory results follow the adoption of proper 
treatment. In every case, if the patient persists in sexual or alco- 
holic excesses or in any way transgresses against the rules of 
sexual hygiene, his ultimate cure will be greatly retarded. 

In young men suffering from the effects of masturbation and 
chronic posterior urethritis the prognosis is, as a rule, good, pro- 
vided the patient is not very anaemic or neurasthenic. In those 
cases in which the morale of the patient is much below par the 
progress toward cure is slow and often unsatisfactory and halting. 
The occurrence of cystitis by extension, particularly in chronic 
masturbators, is of serious import, for such cases are very refrac- 
tory to the most careful forms of treatment. 

In very many older men an excellent prognosis may be given if 
they can control their sexual tendencies by moderation and will 
not overindulge in alcohol. The coexistence of chronic posterior 
urethritis, of seminal vesiculitis, or of chronic inflammation of the 



CHRONIC AFFECTIONS OF THE PROSTATE. 257 

ampullae is a rather serious drawback which may tax the skill 
and patience of the surgeon. Very many of these cases, however, 
are much benefited, and even unpromising ones can be cured. 

Treatment. The first essentials in the treatment of chronic 
prostatitis are a regular, quiet life, abstinence from alcoholics, and 
the avoidance of all kinds of sexual excess or excitement. A 
bland, nutritious diet should be taken, and spices, coffee, cocoa, 
highly seasoned dishes, and asparagus should be avoided. The 
rectum should be thoroughly emptied every day at least once, and 
if the natural evacuation does not occur a mild aperient must be 
taken. These patients must avoid taking cold, and they should 
not take part in violent sports, nor should they indulge in bicycle 
exercise. 

Moderate and rather infrequent sexual intercourse may be 
practised, provided no ill effects are found to follow it. 

When chronic bulbous or posterior urethritis is present active 
treatment must be instituted for the relief of these conditions, 
which materially aggravate the case and render it more rebellious. 
In like manner strictures of the urethra should receive proper 
attention and treatment. (See pp. 222 et seg.) Instillations of 
nitrate of silver, irrigations with watery solutions of the same salt 
(1 to 500, 1000, to 2000), of permanganate of potassium (1 to 
4000 to 10,000), or of sulphate of zinc and alum (1 each to 500 
to 1000), may be given every few days. 

In many cases the careful introduction of a steel sound cooled 
in ice-water, every four to seven days, is most grateful and bene- 
ficial. The psychrophor may be used instead of the sound if the 
surgeon so desires. 

Direct treatment to the prostate by the surgeon may be made 
by means of the finger-tip in the patient's rectum. Preparatory 
to beginning the treatment of massage of the prostate the surgeon 
should acquaint himself with the size of the organ and ascertain 
what part is affected, or whether the totality of the gland is in- 
volved. Then the relative softness, bogginess, and hardness 
should be learned. When the conditions of the organ are ascer- 
tained full details thereof should be noted down for future refer - 

17 



258 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

ence and comparison. The main object is to reduce the size of 
the swollen organ, and by massage we press out pathological 
products (vide supra), stimulate the tissues, and cause the absorp- 
tion of more or less of the inflammatory exudation, by means, 
probably, of the increased circulation in the vessels and lym- 
phatics. In addition to these changes, we undoubtedly give tone 
and resiliency to the flabby bloodvessels and also stimulation to 
the relaxed muscular fibres. A certain healthy stimulus seems to 
be communicated to the nerves of the prostate by judiciously 
administered massage. The technique of the operation is very 
simple. The patient stands with his feet slightly separated and 
bends the body forward at a right angle. Then the surgeon, 
having liberally greased his forefinger with vaseiin, gently inserts 
it until he reaches the prostate. Then, by means of extended 
lateral and up-and-down gentle but firm pressure, he thoroughly 
kneads the organ. Patients act and feel very differently while 
this operation is taking place. Some cry out with pain, particu- 
larly at the first seance, others suffer a little and make no com- 
plaint, while others are entirely passive and perhaps say that the 
sensation is a little unpleasant. In some patients partial or full 
erections are produced, and in almost all of them there is inability 
to urinate for several minutes after the operation. The secretions 
which are expressed have already been described. 

In most cases prostatic massage produces much benefit and 
comfort, but in some it is necessary to proceed very guardedly, 
lest irritation be set up. No absolute rule can be laid down as to 
the frequency of repetition of this treatment. In general, one mas- 
sage in five or seven days, or even ten, will be found sufficient to 
produce good . results. When there is concomitant chronic ure- 
thritis of the bulb, posterior urethritis, or involvement of the 
verumontanum, the patient may be more or less sensitive to this 
procedure, and it behooves the surgeon to proceed slowly and 
carefully. The indications for the continuance and the frequency 
of the massage are the comfort and benefit the patient says he 
experiences, and also the moral effect, which in many cases trans- 
forms a gloomy and worrying patient into a cheerful and hopeful 



CHRONIC AFFECTIONS OF THE PROSTATE. 259 

one. As a rule, when no ill effects are produced, as attested by 
the feeling of general and local comfort experienced by the patient, 
when there is no abnormal desire to urinate, and when pus in un- 
usual quantity does not appear in the urine, the surgeon may be 
certain that he is on the right track, and can continue. He can 
also gain much information by ascertaining from his records how 
much involution in the prostate he has produced, and by repeated 
microscopical examinations in auspicious cases he can convince 
himself that the pus, effete epithelial cells, granular phosphates, 
perhaps tube-casts, prostatic concretions, and amyloid bodies are 
growing less numerous as the patient improves in every partic- 
ular. During the massage treatment rectal irrigations with very 
warm water, administered by means of Kemp's instrument (see 
Fig. 65), are often of signal benefit in causing the involution of 
the swollen organ and the absorption of diseased products. In 
some cases, also, cold water thus administered seems to be very 
beneficial. 

In order to obtain the beneficial effects of heat in the rectum it 
may be necessary to use water of the temperature of 100° to 
120° F. The increase in heat can be accomplished gradually 
until the higher temperature of 130° F. is reached. When hot 
water is thus used, many patients from the very first experience 
great relief and gladly consent to the elevation of the temperature 
of the irrigations. It is probable that these hot rectal applications 
prove beneficial by their stimulant action upon the nerves, the 
bloodvessels, and lymphatics. 

The use of cold water by rectal irrigations should be carefully 
watched, and it should be discontinued at once if discomfort to 
the patient is produced. The temperature of cold irrigations 
should range from 50° F. to that of ice-water. 

Many patients state that their sexual function is much improved 
by the use of the very hot rectal irrigations. 

I know of no morbid condition in which such reliable data can 
be obtained by physical and microscopical examinations of the 
patient and of his urine as are presented by cases of chronic pros- 
tatitis. 



260 SEXUAL DISOBDEBS OF THE MALE AND FEMALE. 

Many cases of chronic prostatitis are much benefited by tonic 
mixtures which contain goodly doses of nitro-muriatic acid com- 
bined with strychnine and quinine. The neurasthenia and weak- 
ness which very often occur in the course of chronic prostatitis 
should be carefully treated. Such patients should receive kindly 
encouragement, and their general well-being should be sedulously 
cared for. 

In addition to systematic local treatment, much benefit may 
follow the internal administration of full doses of fluid extract of 
ergot and strychnine. The muriate tincture of iron combined with 
strychnine is sometimes very efficient, particularly in debilitated 
subjects. 

It is also well to mention mercurial, ichthyol, and iodide of 
potassium suppositories, which should be introduced into the rec- 
tum every night. The inert basis of these suppositories is a mix- 
ture of cocoa-butter and white wax. In each suppository may be 
incorporated twenty grains of strong mercurial ointment, fifteen 
to twenty drops of ichthyol, and thirty grains of the iodide of 
potassium. 

In all cases the surgeon should be on the watch for urethral, 
vesical, and seminal vesicle complications. 

HYPERTROPHY OF THE PROSTATE. 

The scope of this treatise precludes the full consideration of the 
subject of hypertrophy of the prostate, therefore, the genital and 
sexual symptoms induced by this morbid condition will receive 
most attention. 

In all probability many cases of hypertrophy of the prostate 
take their origin in the chronic catarrhal processes already de- 
scribed. In general, it may be said that this morbid state begins 
to develop or to reveal itself by symptoms after the fiftieth year, 
though it may begin at an earlier date. 

Succinctly stated, hypertrophy of the prostate consists largely 
in enormous overgrowths of the gland-tissue of the organ, together 
with increase in the muscular fibres and connective tissue of the 



CHRONIC AFFECTIONS OF THE PROSTATE. 261 

stroma. This overgrowth in most cases occurs in the path of 
least resistance, which is toward the bladder, but it also takes 
place laterally and backward, when it bulges more or less into the 
rectum. "With the lengthening of the lobes the urethra becomes 
elongated, and with the growth of these parts the lumen of the 
canal is impinged upon, and it is rendered smaller, inextensible, 
and very frequently tortuous. In some cases the so-called third 
lobe becomes enlarged into a round or pear-shaped body, which 
acts as a ball-valve at the vesical orifice. In some instances a 
true bar across the lower part of the vesical neck is formed. With 
the increase of this overgrowth at the neck of the bladder, which 
then is no longer dilatable, more or less difficulty in expelling 
the urine is experienced, until in the end in many cases expulsion 
becomes impossible. Some patients state that their first knowl- 
edge of the trouble was revealed to them by their want of power 
to start the urinary stream. 

In many cases the development of enlarged prostate is very 
slow and insidious and unattended with marked symptoms, while 
in others its onset is quite rapid. The most constant symptom is 
frequency of urination, particularly at night. In stricture of the 
urethra this symptom is mostly observed during the day, while 
in old prostatic cases it is complained of at night. After a time 
the patient becomes conscious that the outlet or the neck of the 
bladder is contracted, and that expulsion of the urine causes him 
much greater effort than it did formerly. The stream of urine 
is then small, feeble, often falls perpendicularly on his shoes, is 
sometimes suddenly arrested, and ends in unsatisfactory dribbling. 

With the progressive development of this overgrowth the im- 
pediment to urination increases and the bladder may become over- 
distended, and then chronic incontinence with all its painful symp- 
toms and unpleasant features is observed. Synchronously with 
the overgrowth of the prostate certain hypertrophic changes take 
place in the bladder by which its walls are much thickened and 
its inner surface is rendered rugose and much trabeculated. Early 
or late a pouchy condition of the bladder behind the trigonum 
forms, and a receptacle is thus made in which an increasing quan- 



262 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

tity of urine accumulates which is termed residual urine. As 
the case grows worse the irritation of the neck of the bladder 
becomes more and more painful, and a burning, scalding sensation 
is felt in the whole urethra, together with, in many cases, severe 
pain in the glans penis. After urination some prostatic mucus 
may drip from the meatus. Many patients suffering from hyper- 
trophy of the prostate give evidence of sexual erethism. Erec- 
tions more or less perfect quite constantly occur, and nocturnal 
emissions are not infrequent. In some rare cases these men 
become in a measure sexually perverted, and, not being satisfied 
by coitus, they indulge actively or passively in many unnatural 
practices. As a rule, however, this period of eroticism sooner or 
later passes away and the man lapses into a condition of sexual 
apathy and permanent impotence. In other cases, happily the 
more numerous, as the hypertrophy of the prostate develops and 
its incident sufferings increase, sexual desire slowly or quickly 
dies out. 

Besides the sexual symptoms some patients complain of pain in 
the penis, particularly in the glans, in the testes and scrotum, and 
in the perineum. Many patients complain of uneasy sensations 
and dull pains in the sacral, hypogastric, and lumbar regions, 
which they wrongly attribute to rheumatism and lumbago. Pain 
near the rectum or anus or in the perineum, when in certain posi- 
tions, or when the body is roughly jolted, or on sitting down, is 
not at all infrequent. 

With the progress of the case, when unrelieved, the health 
sooner or later fails. In many cases cystitis becomes a most dis- 
tressing symptom, and this bladder infection creeps up the ureters 
and involves the kidneys. The cystitis causes urinary poison- 
ing, and the damage to the kidney prevents the elimination of 
the effete products of metabolism, so that the patient is really 
doubly poisoned. 

As his diseased conditions grow worse he loses his appetite and 
he becomes thin and sallow. He suffers from a peculiarly dry 
tongue, and his breath has a urinous odor. Then chills and fever 
and marasmus set in, and death ensues. 



CHRONIC AFFECTIONS OF THE PROSTATE. 263 

Treatment. Care should be taken as to the mode of life of the 
patient. He should eat easily digested food in sparing quantities, 
should not overexercise, and should avoid taking cold. It is im- 
portant that his bowels should move freely every day. Spirituous 
liquors should be taken in great moderation. 

In the first stages of hypertrophied prostate in some cases much 
benefit results from the very careful and painless passage of sound 
and bougies, which seem for a time at least to keep the lumen of 
the urethra patulous. Rectal injections of hot or cold water may 
be beneficial. In many cases warm irrigations of the bladder 
and urethra with boric acid and hot water (two drachms to sixteen 
ounces) are very grateful and soothing, and the same may be said 
of very mild warm solutions of nitrate of silver (1 to 5000 to 
20,000), or of permanganate of potassium (1 to 8000 to 10,000). 
Alkalies or acids, as the case demands, may be given internally 
to render the urine bland. Urotropin should be given in decided 
cases of alkalinity of the urine. These patients should be told 
not to try to hold their urine when the desire for expulsion comes 
on. Massage of the prostate may sometimes be very beneficial. 
As a rule, these patients have to resort quite early to the catheter, 
the use of which may make them comfortable for many years. 

In certain selected cases prostatotomy and prostatectomy, ure- 
thral or perineal, may be performed. Castration and vasectomy 
have not proved to be the boons which they were expected to be* 
In many cases permanent perineal or suprapubic drainage may of 
necessity be resorted to. In appropriate cases Bottinr's operation 
may be resorted to. (For a full consideration of this subject, see 
my work A Practical Treatise on Genito-urinary and Venereal 
Diseases and Syphilis. Philadelphia, 1900.) 



CHAPTER XIX. 

INFLAMMATION OF THE SEMINAL VESICLES. 

In some cases seminal vesiculitis is the cause of sexual weak- 
ness, impotence, and of neurasthenia. This affection is really not 
so frequent as it has been claimed to be, yet it is found in a goodly 
number of cases. It is due to chronic gonorrhoea, masturbation, 
and sexual excesses. 

Seminal vesiculitis may be acute or chronic. The acute form 
has many points of analogy with epididymitis. Both affections 
are almost always secondary to gonorrhoea, occurring in the third 
or fourth week, or to hypersemia of the posterior urethra, due to 
masturbation and venereal excesses or to inflammation of this 
region, resulting from traumatism, catheterization, endoscopy, and 
strong injections. In both there are inflammation of the mucous 
membrane and hyperplasia of the connective tissue. In epididy- 
mitis the testicle does not swell, and in seminal vesiculitis the 
prostate is not usually affected. In both cases suppuration, in 
the sense of abscess-formation, is the exception and resolution the 
rule. 

Symptoms. The symptoms of the acute form of seminal vesic- 
ulitis are quite similar to those of posterior urethritis and to those 
given as diagnostic of the severe varieties of prostatitis. The 
patient first experiences pain, either of a dull or throbbing char- 
acter, or a sensation of weight, which he refers to the deep portion 
of the pelvis just within the anus or at the neck of the bladder or 
in the perineum. There is markedly increased frequency of uri- 
nation with tenesmus, sometimes mild, again quite decided, and in 
some cases very severe. As the bladder fills the painful symp- 
toms increase in severity, and there may be pain at the end and 
sometimes at the root of the penis. There may be fever, chills, 
and malaise. All these symptoms may be present in posterior 



INFLAMMATION OF THE SEMINAL VESICLES. 265 

urethritis, so that the crucial test iu diagnosis is palpation of the 
prostate and seminal vesicles by means of the finger in the rectum. 
If the case is one of acute posterior urethritis the prostate may be 
tender, even painful, on pressure, and perhaps swollen. If 
seminal vesiculitis is present and explored for early, one or both 
vesicles will be found to be much enlarged in all directions in the 
shape of a distended leech, hot, brawny, and exquisitely tender. 
In a few days the swelling may still further increase, and then 
moderate fiuctuation may be felt. In some of these cases the 
patient presents a pitiable spectacle. He suffers from pain in the 
perineum, rectum, bladder, and at the top of the sacrum. He has 
frequent desire to urinate, and the act is attended with much pain, 
or, again, in some cases, there is very distressing dysuria. Defe- 
cation is very painful, and perhaps complicated with rectal tenes- 
mus, and may be attended with vesical spasms ; sleep is heavy 
and unrefreshing, and often during the night painful erections and 
pollutions, perhaps bloody, may add to the patient's sufferings. 
The urine may contain pus and epithelial cells, but these tissue- 
elements may be absent for hours or for days, during which the 
urine is clear ; and in this feature acute seminal vesiculitis differs 
from acute posterior urethritis, in which the discharge of pus or 
blood is constantly seen. At the onset, and early in the course, 
of seminal vesiculitis the gonorrhoea! discharge may disappear 
entirely, and in this it resembles epididymitis. But in a short 
time the discharge reappears, and it may be more or less bloody. 
In seminal vesiculitis the blood is mixed with the pus or the latter 
is streaked with it, whereas in posterior urethritis the blood fol- 
lows the act of urination, or there may be a worm-like thread of 
coagulated blood with the first jet of the urine. 

The inflammatory stage of seminal vesiculitis usually pursues 
a course similar to that of epididymitis, and at the end of a week 
or ten days the symptoms become ameliorated, and resolution 
gradually sets in. In all probability, in many cases the parts 
sooner or later become normal again. In some cases after resolu- 
tion of the vesicular inflammation the urethral discharge reappears, 
while in others the urethra is left in a healthy condition. In this 



266 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

acute stage of inflammation the morbid process resembles that of 
gonorrhoea in the redness and swelling of the mucous membrane 
and in the submucous cell-increase. When, however, the phleg- 
masia becomes intense a true suppurative process or abscess forms, 
in which event the local and general symptoms are more pro- 
nounced and the suffering of the patient greater. Rectal explora- 
tion then reveals a large boggy, painful swelling at the base of the 
bladder, beyond and to the outer edge of the prostate. This 
swelling is very large when both vesicles are involved. 

While the ejaculatory duct of the seminal vesicle remains patu- 
lous the contained pus may escape, or perhaps may be milked, by 
means of the finger-tip, into the urethra, in which event full reso- 
lution without ulterior bad results may occur. If, however, the 
duct becomes occluded by the swelling of its mucous membrane 
or by being plugged up by sympexia or masses of mucus dislodged 
from the diverticula of the vesicle, the abscess may attain a very 
large size, and, if not promptly incised and its contents evacuated 
the pus may perforate its walls and burst into the ischiorectal 
fossa or around the rectum into the bladder, the rectum, and the 
peritoneum, sometimes causing death and generally leading to the 
formation of fistulous tracts which are very difficult to cure. 

It is stated that the abscess never ruptures into both bladder 
and rectum. In any of these very painful events examination of 
the parts is necessary, and from it the line of operative procedure 
will be arrived at. The intimate relations of the vas deferens, 
the ejaculatory duct, and the seminal vesicle are such that the last 
structures and the testicles may be involved at the same time. It 
is probable that in some cases seminal vesiculitis and epididymitis 
coexist, but that the violence of the symptoms of the testicular 
trouble masks those of the vesicular affection. It is also very 
probable that the intrapelvic pain which so frequently accom- 
panies acute epididymitis, and which we have been taught is due to 
a complicating phlegmasia of the pelvic part of the vas deferens, 
is sometimes really symptomatic of involvement of the seminal 
vesicle. The statement that this affection is a common accom- 
paniment of gonorrhoeal epididymitis needs confirmation. 



INFLAMMATION OF THE SEMINAL VESICLES. 267 

It can be readily understood, after a consideration of the fore- 
going facts, why acute seminal vesiculitis has often been wrongly 
diagnosticated as posterior urethritis and acute prostatitis, and by 
niany, under the influence of old ideas, as inflammation of the 
vesical neck and floor of the bladder. 



CHRONIC SEMINAL VESICULITIS. 

This form of seminal vesiculitis may result from the non-occur- 
rence of resolution in the acute affection, and in this event the 
clinical history is tolerably clear and striking. But in the 
majority of cases of chronic seminal vesiculitis it begins as a low- 
grade inflammatory process in persons, particularly of neurotic or 
neurasthenic types, who may suffer from chronic subacute poste- 
rior urethritis or chronic prostatitis, and in confirmed masturbators 
and in those given to excessive venery and alcoholics. The diffi- 
culty in the study of the chronic form of seminal vesiculitis is 
that in many cases the symptoms are so few and so vague, and 
point so indefinitely, if at all, to trouble in the vesicles, that 
oftentimes their origin is not suspected by the surgeon. Then, 
again, cases are seen in which the symptoms are very clearly and 
strongly marked, yet they may be with seemingly good reason 
attributed to trouble in the posterior urethra and in the prostate. 

Cases of seminal vesiculitis which follow quite directly a recent 
or more or less remote attack of gonorrhoea very often present such 
a group of symptoms that the surgeon is led to suspect their origin 
in inflammation of the seminal vesicles, particularly if no trouble 
is found in the posterior urethra. Such patients, who are usually 
young men and not over thirty years of age, state that since an 
attack of gonorrhoea or a relapse they have not felt well as regards 
their sexual organs. Some complain that they are sexually weak, 
that they have little desire, or that they have premature and per- 
haps painful ejaculations, which in some cases are mixed with 
blood. Others, again, are subject to a constant slight or profuse 
discharge, which is of a mucous or mucopurulent character. 
Again, this form of discharge may be intermittent. There may 



268 SEXUAL DISORDERS OF THE MALE AND FEMALE. 



be, however, a decided chronic seminal vesiculitis without any 
discharge which is perceptible. Not infrequently patients having 
a history of one or more attacks of gonorrhoea state that they 
suffer with a mild or moderately severe, even burning, pain or 
itching, or a sense of weight in the course of the urethra, in the 
perineum, bladder, anus, and rectum. In addition to this, they 
often give a history of sexual erethism with or without gratifica- 
tion in coitus, and sometimes of increased desire, while little relief, 
and even aggravation of the symptoms, may follow the sexual act. 
All of these symptoms may be present in cases of chronic 
prostatitis. 




Secretion of chronic seminal vesiculitis. 

Chronic seminal vesiculitis in younger men consists in a sub- 
mucous round-cell infiltration beneath the mucous membrane, 
which gives rise to hyperemia and purulent catarrh. If care be 
taken to cleanse the urethra of the discharge from posterior ure- 
thritis and from any form of prostatitis (if these morbid conditions 
coexist), a grayish or brownish mucus can be expressed in some 
cases from the vesicles by the finger-tip in the rectum. This secre- 



INFLAMMATION OF THE SEMINAL VESICLES. 269 

tion may be very copious or decidedly moderate in quantity. It 
is very viscous, and in the earlier days of the inflammation it may 
be tinged with blood or pus more or less abundantly. When this 
secretion is examined by means of the microscope it will be found 
to contain vesicular mucus in large and small globules, granular 
and perhaps crystalline phosphates, pus-cells (perhaps red cor- 
puscles), and spermatozoa, which in most cases are lifeless. These 
features are well shown in Fig. 74, the secretion having been 
gotten by massage from a patient and examined by myself. These 
appearances are quite constantly found in the secretion of cases of 
young men in whom, though the affection is chronic, it has not 
yet reached its full development. In these cases, which, by their 
clinical history and their secretion, seem to constitute a distinct 
class, the cell-infiltration and consequent thickening of the walls 
and structural damage of the vesicles are not yet very great, and 
the prognosis generally is better than in more advanced cases. 

More Advanced Form of Seminal Vesiculitis. 

In the cases of pronounced masturbators, in old gonorrhoeics, in 
those given to excessive indulgence, particularly with the addition 
of alcoholic excesses, chronic seminal vesiculitis may sometimes be 
found in a more severe form. These cases are often those of 
anaemic, neurotic, and neurasthenic subjects who respond very 
indifferently to treatment. Such patients, who are usually beyond 
thirty years of age, in whom the affection is very chronic, may 
complain of some pain or disturbance in the urethra, bladder, 
anus, or rectum, and they may present a discharge ; then, again, 
all these symptoms may be wanting. Most of them, however, 
give a history of disturbance in the sexual function similar to 
those just detailed. These disturbances are mainly of two forms : 
first, those of lowered power, and, second, those of erethism of the 
sexual organs. In the first order of cases we find absence or 
incompleteness of erections, emissions from slight causes, without 
enlargement of the penis. In these cases there is often a haunt- 
ing desire for erection, with no response. Very often these 
patients suffer from a constant dribbling of a dirty-gray or 



270 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

brownish mucus, which may during the day be so copious as to 
saturate one or two pocket-handkerchiefs. Then, again, some of 
these patients have no such discharge, but an emission of a thin, 
gray, watery, and sometimes brownish and even curdy fluid occurs 
daily or more frequently. 

In these advanced cases, particularly in subjects who are ap- 
proaching middle life, the structural changes in the vesicles are 
much more pronounced than they are in the earlier class of cases. 
The submucous infiltration will then be found to have thickened 
the walls of these sacs very much, and in some cases there will 
be found a very decided increase in the density and quantity of 
the perivesicular connective tissue ; whereas in the earlier class of 
cases the vesicles to the touch feel like a distended leech, and are 
yet compressible. In the most advanced cases these structures 
are firm, perhaps very resistant, and they convey to the mind, by 
means of the finger-tip, the impression that a well-defined, com- 
pact, perhaps indurated, mass has taken the place of a tolerably 
soft sac. The conglomerate morbid process then consists of epi- 
thelial hypertrophy, submucous round-cell infiltration, general 
increase in the connective tissue stroma, and much hypertrophy of 
the perivesicular fibrous tissues. In these cases, as time goes on, 
contraction takes place in the newly formed morbid tissues, and 
the calibre of the chambers of the vesicles becomes much con- 
tracted. In this event the muscular contractile function of these 
sacs is more or less impaired or is wholly lost. 

When a post-mortem specimen of the seminal vesicles in the 
less advanced form of the morbid process is examined, it is often 
found that the calibre of the vesicles and of their chambers has not 
been materially decreased, and that, although the walls are thicker 
than normal, they are yet compressible and tolerably extensible. 
In the older cases above mentioned the rigidity of the parts con- 
trasts strongly with the condition just now described. 

The normal secretion of the seminal vesicles is of a dull gray 
color, perhaps slightly tinged with light brown. In disease this 
secretion becomes more and more brown. In the less advanced 
class of cases it is of a yellowish-brown color, and in the advanced 



PLATE X. 



°°0- ^ ;';^ 



«>o 






>Q W „, ( ©. 







c 



6) „ 



'■Q 




Secretion of Very Chronic Seminal Vesiculitis, Containing 

Phosphatic Concretions, Granular Phosphates, 

Sympexia, Pus Cells, Mucoid 

Globules and Spermatozoa. 



INFLAMMATION OF THE SEMINAL VESICLES. 271 

cases it is of a very pronounced dirty, sometimes rusty, brown 
color. In the diseased condition, as age advances, the secretion 
becomes much more viscid than it is normally. 

The dark color of the secretion in very chronic seminal vesicu- 
litis is due mainly to phosphatic concretions held together by 
mucus and more or less stained with blood-pigment. Then we 
also find large round or oval masses of the dried mucus peculiar 
to the vesicles, which seem to have become stained by blood and 
to have become condensed into spheres. Further than this will be 
found large, flat, irregular plates of epithelial cells grouped together 
in a chaotic mass and deeply tinged with yellow pigment derived 
from the blood. These are the main constituents of the secretion 
of very chronic seminal vesiculitis, and their presence is very con- 
stant, as I have often observed. In addition, we find more or less 
granular phosphates, very often of a yellowish color, red blood- 
cells, pus-cells in varying quantity, and spermatozoa, which are, 
as a rule, dead. 

In Plate X. the secretion of very chronic seminal vesiculitis is 
well shown. The secretion used in the preparation of the plate 
was drawn by me from the seminal vesicles of a man, aged forty- 
two, who died of alcoholism, and who in life suffered from chronic 
seminal vesiculitis. 

I have found in post-mortem specimens that the secretion of 
the seminal vesicles in health and in disease is exactly like that of 
the deferential ampullations, except that perhaps spermatozoa may 
be rather more numerous in the latter secretion. Now, as these 
parts are so closely coapted, and as their function and structure 
are precisely similar, it is very probable that the ampullations are 
also involved in some cases of seminal vesiculitis, and it may 
happen that the disease may be limited to the ampullations. In 
the living subject I can well conceive that it would be sometimes 
very difficult to diagnosticate, by means of the finger-tip in the 
rectum, between chronic seminal vesiculitis and chronic inflamma- 
tion of the ampullations. I have before me, as I write, the 
seminal vesicles of a man which are the seat of advanced chronic 
inflammation, and their structural condition and their secretion 



272 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

are precisely similar to those of the ampliations which lie in close 
contact at the inner side of the vesicles. If such a case were 
examined in life, in the light of our present ideas, the diagnosis 
of chronic seminal vesiculitis would be unhesitatingly made. It 
is probable, therefore, that in cases of chronic, and perhaps acute, 
seminal vesiculitis the ampullae may also be involved by the same 
morbid change. 

Such is the erotic condition of some patients suffering from 
chronic seminal vesiculitis, that the sight of a pretty woman, of 
her breast or her ankle, throws them into a high state of nervous- 
ness and sexual erethism. I have known several instances in 
which one woman only exerted this morbid influence upon the 
man. Accidental slight contact, the glance of the eye, the sound 
of the voice, and the grasp of the hand served to so excite and 
exalt them sexually that an orgasm, with or without partial erec- 
tion, would result. This erotic condition is also not infrequently 
observed in men suffering from chronic catarrhal prostatitis. 

These cases, as we may term them very chronic, run a some- 
what peculiar course. In some the symptoms and conditions con- 
tinue in a more or less subdued manner, and though they disturb 
the patients considerably, the latter arrive at a state of mind by 
which they bear their troubles more or less philosophically. In 
this class of cases the affection runs on from year to year in a 
monotonous way. Such patients are neither healthy nor very sick. 
But cases are sometimes seen in which the chronic, uneventful 
course of the affection is varied by the development of more or 
less severe exacerbations. In this event the health becomes dete- 
riorated, the patients lose their appetite and weight, and present 
the appearance of very weak and sick men. Concurrently with 
this condition the nervous system becomes much disturbed and the 
patients present the symptoms of neurasthenia. A nervous appre- 
hension and anxiety are very frequent concomitants. Such an 
exacerbation may last months or years, and may lead to perma- 
nent invalidism. 

In old men suffering from hypertrophy of the prostate a low 
grade of seminal vesiculitis is a not uncommon accompaniment. 



INFLAMMATION OF THE SEMINAL VESICLES. 



16 



In many of these cases the vesicular complication passes unnoticed, 
for the reason that it may give rise to no symptoms at all, or, if 
present, they are not pronounced in character. Then, again, they 
may be masked by the disturbances produced by the prostatic 
affection. 

Diagnosis. The diagnosis of seminal vesiculitis, in whatever 
form it may exist, is to be arrived at mainly through palpation 
of the parts by the finger inserted into the rectum. It has already 
been shown how little light the subjective symptoms throw upon 
the nature of the trouble. It is not, as a rule, as easy as it is 
claimed to be by some to make out clearly the outlines and dimen- 
sions of the seminal vesicles. In the examination some authors 
state that the patient should stand and bend the body forward 
as far as he can, his feet being about a foot apart. It is always 
well that the bladder should be full, for in that condition the 
vesicles are more readily detected. Then the finger is introduced 
to the prostate, and, having defined its outline, the vesicles are 
sought for above and to the outside of this body. 

This examination can also be made with the patient on his 
back, in which event the bladder, being full, tends to sag down 
in the pelvis. It is easy to conceive that in some patients in the 
bending-forward-and-standing position the bladder may tilt for- 
ward toward the abdominal wall, and then the vesicles will be 
more inaccessible. 

At the prostate the two vesicles approach to within a finger's 
breadth of one another, and on the inner side of each one is the 
vas deferens, which at this part becomes much enlarged and 
ampullated. I ruyself think that very often the ampullation of 
the vas deferens, which may be increased in size by the gonor- 
rheal or chronic hyperaemic process, is mistaken for enlargement 
of the seminal vesicles. It certainly is next to impossible to say 
from rectal examination in life that the vas deferens is not swollen 
and the vesicle is. These parts are in such intimate juxtaposition 
that it is nearly impossible to distinguish between the two. It is 
important, also, to have a good knowledge of the structure and 
physical characters of the vesicles in their normal state. To this 

18 



274 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

end study on healthy men is necessary. The seminal vesicles in 
health have a firm, somewhat resistant structure, which, while not 
presenting a brawny feel to the touch, give the sensation of having 
tolerably thick Avails. Therefore, the surgeon must not enter upon 
the examination with the idea that he is to always feel two oblong, 
rather soft, and readily compressible little bladders. 

If diseased, the seminal vesicles will, in the acute stage, feel 
much swollen in all directions, tender, perhaps hot, and may 
present a doughy sensation, like that of the over-filled leech. In 
the stage of abscess the swelling will be great, the pain intense, 
and the symptoms severe and pointing to intrapelvic trouble. 

In the chronic forms a quite firm tumor may be felt. If both 
vesicles are involved, the base of the bladder beyond the prostate 
is the seat of the tumor, which is usually of goodly size, often 
very large. Abdominal pressure, exerted deep down and toward 
the pelvis, may often afford much aid in these examinations. Some 
authors lay stress upon the presence of a sound in the bladder, 
pushing its base downward toward the rectum, as being of great 
help to the finger in the rectum. Perhaps in some cases this pro- 
cedure may be admissible or practicable, but it should never be 
resorted to without due thought concerning the nature of the case 
and the state of the deep urethra and prostate. In all acute cases 
the introduction of the sound as an accessory aid to diagnosis is 
strictly interdicted. In chronic cases the surgeon must always 
remember that the posterior urethra may be the seat of a low 
grade of inflammation, and that the prostate may also be at least 
hyperaemic. This same caution applies very strongly to the cases 
of old men who are suffering from enlargement of the prostate and 
also from a chronic inflammatory condition of the seminal vesicles 
— a complication, as we have seen, which is sometimes met with. 

Examination and manipulation of the seminal vesicles by means 
of the finger-tip cause a flow of pus, with perhaps blood, into the 
urethra Avhen the inflammation is recent and active. In the sub- 
acute eases the discharge is mucopurulent and mucoid. 

Pathology. In the acute gonorrhoeal stage it is probable that 
the lesion of the mucous membrane is similar to that of gonor- 



INFLAMMATION OF THE SEMINAL VESICLES. 275 

rhoea of the urethra. This is a field worthy of careful study. 
As yet the observations have been macroscopical rather than 
microscopical. In the main, the morbid process consists of swell- 
ing of the mucous membrane and small-cell thickening in the sub- 
mucous connective tissue. The vesicles then may be much dilated, 
or, again, they may, by contraction of the newly-formed tissue, 
become much shrivelled. Within the vesicles a brownish mucus, 
muco-pus, spermatozoa (alive or dead), sympexia, and calcareous 
concretions may be found. 

Prognosis. In the acute form of this trouble resolution usually 
takes place. In the chronic forms amelioration and cure may be 
obtained. In some cases, however, the morbid process goes on to 
the formation of large tumors which require operative measures. 
Tubercular infiltration of the seminal vesicles may perhaps undergo 
resolution or lead to cicatrization or caseation, but in most cases it 
is continuous with or concomitant to a similar affection of other 
organs, and in the end death results. In malignant new-growths 
a lethal outcome is inevitable. 

Treatment. When recognized in the acute stage seminal vesic- 
ulitis is to be treated on the general principles which govern the 
management of all acute phlegmasia? of the genital and urinary 
organs. In some cases it is well to apply a large number of 
leeches upon the perineum and the margin of the anus. Injec- 
tions of cold water may be used, and the rectum may be packed 
with ice if the procedure is pleasant to the patient, or hot irriga- 
tions may be administered by means of Kemp's rectal cooler. 
(See Fig. 60.) These applications may be used once or twice a 
day, or even more frequently. Opium in suppositories, diluents, 
and saline cathartics may be administered as necessity requires. 

Should an abscess form it may be reached by means of a curved 
incision in the perineum just anterior (about three-quarters of an 
inch) to the anus, great care being taken that the membranous 
urethra, the prostate, and the rectum are not cut. In this opera- 
tion much aid will be given by means of the finger in the rectum 
and a sound in the urethra. The incision may be made in the 
median line laterally, or, if both vesicles are the seat of acute 



276 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

suppuration, it may be crescentic. Then the dissection between 
the base of the bladder and the rectum must be cautiously made. 
The resulting cavity should be treated on general surgical prin- 
ciples. 

In the treatment of chronic seminal vesiculitis, in which we may 
find distended, pouchy, or brawny vesicles, it is well to carefully 
massage the parts. This procedure is accomplished by the finger- 
tip gently but firmly pressing or kneading as much of the organ 
as is within reach from above downward, so as to express the con- 
tents through the ejaculatory duct into the prostatic urethra. The 
patient should lie on his back, or if in the erect position he should 
bend his body at a right angle to his lower extremities, and in 
this position the surgeon introduces the finger, all the Avhile 
making counter-pressure on the abdomen, the bladder being, if 
possible, well filled. As has already been said, it is no easy matter 
in many cases to reach the vesicles and clearly define their size 
and shape, even when every favoring condition is present. Then, 
again, at the best, only the lower half of the vesicle is really ac- 
cessible to the massaging process. Further than this, it must be 
clearly remembered, as has already been pointed out, that the 
seminal vesicles are made up of blind-ended tubes or diverticula, 
and that they have not the structure and arrangement of racemose 
glands, firm pressure on which will cause the contents to exude 
into the excretory duct. An inspection of Fig. 9 will clearly 
show that it is a physical impossibility to cause the contents of 
the third tube — or, as we call it, the handle of the jack-knife — to 
exude into the urethra, for the reason that it is a blind sac or 
pouch, its non-patulous part ending downward near the pros- 
tate. This portion of the vesicle is fully as large as the other 
two-thirds are, and the contents of this large part cannot in any 
way be extruded into the urethra. For anatomical reasons it will 
be clearly seen that the utmost that can be accomplished in mas- 
saging a vesicle is to act upon about one-quarter of its whole struc- 
ture. In theory, massaging the vesicles seems to be a rational treat- 
ment, in that it seeks to rid these organs of retained chronic inflam- 
matory matter and to restore the tone in muscular and mucous 



INFLAMMATION OF THE SEMINAL VESICLES. 277 

tissues which have become relaxed and flabby. Undoubtedly, in 
many cases benefit does result from the procedure. 

The treatment of the cases of chronic seminal vesiculitis in 
which there are neurasthenia, debility, and often great mental 
depression, belongs largely to the domain of general medicine. 
Such cases require good hygiene, and, if possible, an entire change 
of scene, rest, and pleasant surroundings. Tonics, combined with 
mix vomica and ergot, produce much benefit. Iron, quinine, and 
cocoa are also indispensable in some cases. The urethra, bladder, 
prostate, and seminal vesicles should be very carefully examined 
by instruments and by inspection of the urine and expressed secre- 
tions. If there is, as so frequently happens, a coexistent posterior 
urethritis or prostatitis, these morbid conditions should be properly 
treated. 



CHAPTER XX. 

VAEICOCELE. 

Varicocele is that varicose condition of the spermatic veins 
by which a localized or generalized swelling of the scrotum is 
produced. 

As a rule, when the tumor is small it is a simple, painless affec- 
tion ; but when the swelling is large it may cause sensations of 
dragging weight which extend to the parts beyond, and are more 
severe in hot weather and after bodily exertion. In some cases 
there is a dull, aching, intermittent pain ; in others the pain is 
sharp and crampy. 

To the eye and to digital examination varicocele reveals itself 
(1) as an elongated, diffuse swelling, which extends from the 
external abdominal ring down to the testicle, and is larger higher 
up than lower down ; (2) as a diffuse tumor surrounding the tes- 
ticle, particularly its upper part, and extending half-way up to 
the external abdominal ring, and (3) as a goodly sized tumor just 
below the ring and extending half-way down to the testis. 

When a varicocele is palpated a sensation is conveyed to the 
fingers like that of a mass of earthworms, and this simile is some- 
times rendered all the more striking by the contraction of the cre- 
master muscle. Very often the scrotum is lax and dependent, 
and in its walls tortuous, flaccid veins can be distinctly seen. 
(See Fig. 75.) Under the influence of cold the scrotum and its 
varicocele contract materially, while heat and excitation tend to 
produce laxity and elongation of the parts. 

Varicocele is mostly observed on the left side of the scrotum ; 
exceptionally it is found on both sides. 

The causes of varicocele are : the entrance of the left spermatic 
at right angles into the corresponding renal vein, pressure on the 
spermatic vein by rectal and intestinal distention, and by tumors 



VARICOCELE. 



279 



in the groin and within the abdomen. Incompetence of the cre- 
master mnscle may act as a contributory cause. 

Although in former years it was claimed that varicocele was the 
direct cause of atrophy of the testis, this view to-day has few sup- 
porters. The truth of the matter is that, as a result of varicocele, 

Fig. 75. 




Varicocele and varicose enlargement of the veins of scrotal walls 



there is usually at the time of testicular increase in the years 
preceding puberty an arrest of development. As a result, we find 
small, soft, and sometimes quite insensitive testes, which are ill 
fitted to produce spermatozoa. It is very probable that, owing to 
the disturbance in the circulation of the organ by the backward 
pressure of the blood, its spermatogenic function is interfered with 



280 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

and perhaps held in abeyance. The organ is not necessarily 
sterile ; with the removal of the varicocele by operation the nutri- 
tion of the testis will become re-established, the organ will grow 
in size and firmness, and its function will soon be restored. I 
have seen this result so often, and there are so many well-attested 
reported cases in proof of the statement here ventured, that I 
make it without hesitation or reserve. In all probability, in those 
eases in which atrophy of the testis has been found associated with 
varicocele of the same side, the mischief has been produced by 
some antecedent cause, such as hereditary syphilis, gonorrhoea 
(which is found even in infants and young children) tuberculosis, 
or traumatisms. In many reported cases of atrophy of the testis 
there is evidence of want of thorough clinical investigation, and 
the impression left on one's mind is that the surgeon jumped to 
the conclusion that the varicocele was the morbid factor. Some 
authorities, however, are willing to admit that very exceptionally 
atrophy of the testis may result from uncomplicated varicocele. 

In most cases varicocele causes its bearer very little, if any, 
mental disturbance. This is the case usually in subjects who are 
mentally and physically in good condition, and who are not 
addicted to masturbation. In weakly, lascivious, and neurotic sub- 
jects this condition of the spermatic veins causes a, state of mind 
which is to be described presently. I have several times observed 
that when in excellent health subjects having varicocele gave 
themselves no concern regarding the affection, and that in a state 
of debility and worry from business or other troubles their minds 
became fixed on the scrotal tumor, and they gave way to apprehen- 
sion and anxiety. 

There is no evidence at hand to prove the contention that vari- 
cocele is a result of masturbation. The occurrence of the venous 
anomaly in the persons of confirmed masturbators is no proof that 
the deformity was produced by this bad habit. When boys or 
men have been addicted to masturbation the development and 
detection of varicocele sometimes cause in their minds much dis- 
quietude, and even worry, and they often very wrongfully asso- 
ciate the two as effect and cause. Indeed, the reverse of what is 



VARICOCELE. 281 

generally believed is true. The irritation of the varicocele and 
the condition of disturbed nutrition in the testis lead to much 
sexual irritation and increased desire, and as a result of these the 
patient may fall into the bad habits of masturbation and other 
depraved practices. This erethism of the sexual parts occurs at 
a very bad time for the patient — namely, when he is in the pro- 
cess of evolution from the condition of the child to the maturity 
of puberty, at which time his sexual apparatus is vigorously grow- 
ing and when his inclinations to coitus are beginning to be felt 
very keenly. As the habit of masturbation increases an irrita- 
tive hyperemia develops in the prostate, ejaculatory ducts, and 
perhaps as far back as the seminal vesicles and deferential ampl- 
iations. This syndrome of morbid conditions then further includes 
pollutions and abnormal seminal discharges. Thus, beginning in 
local testicular irritation, the whole sexual apparatus may be 
thrown into a seriously morbid state by reason of the masturba- 
tion and the disturbed mental condition which ensues. Many of 
these patients become much worried and depressed, while others 
become very melancholic, and some even show evidences of mild 
monomania. 

In young men who are engaged to be married, and who pass 
much time in the society of their fiancees, sexual erethism and un- 
gratified coitus may be so severe and protracted that the mind or 
the health of the individual may be somewhat disturbed. These 
young men come to the surgeon complaining of a sense of weight, 
fulness, or even of pain in the spermatic veins. If there is a 
moderate or pronounced varicocele present, the patient may give 
himself up so much to worry and anxiety that his life becomes a 
burden. These patients are prone to think that impotence is im- 
pending, and that they will be unable to consummate matrimony. 
If in this unhappy state of mind nightly emissions occur, or if, 
when in the presence of their fiancees, a glycerin-like mucus 
(urethorrhoea ex libidine) escapes from the meatus, their cup of 
woe becomes filled to the brim. Yet in these cases the mental 
condition is really their only source of danger, since the physical 
condition can be relieved. Plain, sensible, kindly advice and a 



282 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

little treatment usually bring these patients out of their sorrowful 
position. Iu some instances the moral effect of removal by opera- 
tion of the varicocele is most gratifying. 

The simple existence of a very small varicocele in some patients 
causes much depression and dejection, and in some well-marked 
neurasthenia, such as we see in subjects who imagine that they 
have some deep-seated sexual disorder or some undefined or un- 
definable rectal trouble. 

Then, again, the presence of varicocele so operates on the minds 
of some patients that they imagine they are impotent, and this 
state leads to no end of worry and dejection. In this frame of 
mind they may try to indulge in sexual intercourse, and they 
usually fail signally. As a result, such patients become almost 
unalterably convinced that they are impotent, and their distress of 
mind and general unhealthy, cachectic, and woe-begone appear- 
ance really make them pitiable objects. This state of mind is 
very often further increased by the base misrepresentations of 
quacks. Patients in this deplorable state require very careful 
management. They should, first of all, be assured that the impo- 
tence is only temporary, and that it is largely due to their unbal- 
anced state of mind. Then proper attention should be given to 
their general health, to their sexual hygiene, and also to their 
local disturbances. 

Treatment. For the less developed class of cases cold-water 
affusions, used night and morning, and a nicely fitting suspensory 
bandage worn during the day, will give the patient comfort and 
contentment. 

When radical measures are necessary the open operation, with 
ligation and ablation of the venous mass, is by all means to 
be commended, since it always produces beneficial results. In 
all cases of varicocele the condition of the patient's mind must 
be taken into consideration. In such cases good, kindly, reas- 
suring advice, with the regulation, as far as possible, of sexual 
hygiene and coitus, will bring back health and gladness to the 
sufferer. 

The radical cure of varicocele can be effected by a number of 



VARICOCELE. 283 

surgical procedures, many of which are complicated and attended 
with difficult after-treatment, and need not be mentioned. 

The two operations now mostly employed are Howse's opera- 
tion for excision, and its modification by Bennett. The results of 
the open operation are conspicuously and uniformly good. The 
parts are so clearly exposed, the ligatures can be applied with 
such precision, and there is so much simplicity about the operation 
that it cannot be commended too highly. 

It is necessary to remember that the veins to be excised are 
those of the pampiniform plexus, which are surrounded by a well- 
defined connective tissue sheath. These spermatic veins lie well 
in front, while the vas deferens with its artery and veins are fur- 
ther backward and inward in the scrotum. If the testis is care- 
fully pulled downward, the vas is put on the stretch, and it can 
easily be felt, it being hard and firm like a whip-cord. The vas 
and the deferential artery and veins should be carefully avoided. 
Only by gross carelessness will they be included in the ligation of 
the veins. In that event there may be sloughing of the testicle 
from want of blood-supply. 

Excision of the Spermatic Veins. The patient is properly 
prepared for the operation and placed under the influence of ether. 
The hairs of the abdomen and genitals must be thoroughly shaved, 
and the parts — the scrotum especially — well washed with soap 
and water, then with alcohol and ether, and then with bichloride 
solution (1 : 2000). An assistant holds the testicle firmly and 
draws it horizontally downward between the thighs. The parts 
are then tense, the veins can be distinctly felt, and under them 
the vas is very perceptible. An incision is then made for an inch 
and a half in the longitudinal direction and over the prominence 
of the veins. The edges of the wound are then separated by re- 
tractors, and the coverings of the cord are carefully dissected until 
the sheath of the veins comes into view. It presents a shining, 
whitish-gray color, through which the purple veins are seen. 
This sheath of the pampiniform plexus, which must not be cut 
into, is then isolated with the knife, aided by the fingers, and 
then the ligatures, of good, strong catgut, are to be applied by 



•284 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

moans of an eyed probe or aneurism-needle about an inch and a 
half apart. The lower ligature is tied first, and then the upper 
one. The vessels are then cut with scissors about a quarter of an 
inch from the ligatures. The wound cavity is then copiously 
irrigated, and put on the stretch, so as to bring the two edges of 
the scrotum in coaptation. This can be done with the fingers or 
by means of two blunt hooks, one at each end of the wound. 
Five or six, or perhaps more, catgut sutures are now applied, 
thus firmly fixing the parts. A small opening in the dependent 
part of the wound is left for drainage. Usually no drainage- 
tube is necessary. The continuous or interrupted suture may 
also be used. 

Bennett's modification of the foregoing operation is the one I 
now most commonly employ, since its results are so uniformly 
satisfactory. I can do no better than to quote Mr. Bennett's 
words. He says : " The precise extent of the varicocele which 
it is desirable to resect in any given case is best determined by 
placing the patient in the standing position and roughly estimat- 
ing with the eye — or, better, by measuring with a tape — the 
degree of elongation of the cord ; for instance, should the testis be 
three inches lower than normal, then certainly not less than three 
inches of veins should be included between the two ligatures, as 
it will be desirable to excise at least two inches and a half." 
Bennett dissects down to the sheath of the fascia, which he also 
says should not be opened ; then he passes his two ligatures, ties, 
and leaves them quite long. Then he cuts out the segment of 
the veins included between the ligatures. " The cut-ends of the 
stumps left by the division of the varicocele are then brought 
together and retained in permanent apposition by knotting the 
ends of the upper ligature to those of the lower, thus at once rais- 
ing the testis to about its natural level. The ligatured ends are 
cut off quite short." 

Then, after the operation, the wound may be dusted with iodo- 
form and a sterile gauze dressing, and a spica bandage may be 
applied. The first dressing may remain on for several days. 
Perfect healing usually occurs as early as seven and as late as ten 



VARICOCELE. 285 

or twelve days ; very rarely is it delayed longer. "When healing- 
has occurred a callous mass will be felt at the point of juncture 
of the ends of the veins. This will gradually be absorbed, and 
in the end a little firm nodule will be felt. It is well to cause 
the patient to wear a suspensory bandage for a short time after 
any of the radical operations for varicocele. 

The patient is usually confined to his bed for a week. 

Subcutaneous ligation for varicocele is an inexact and unsur- 
gical operation, and is to-day practically obsolete. 



CHAPTER XXI. 

MASTURBATION IN MALE SUBJECTS. 

Certain morbid conditions of the genital tract and disturb- 
ances of the sexual function, with more or less lowering of the 
morale of the patient, have their origin in excessive and long-con- 
tinued masturbation and sexual excesses. Much exaggeration has 
been indulged in, and an unnecessary amount of sentiment has 
been bestowed by lay and medical writers, and notably by quacks, 
on the habit of self-abuse ; therefore, it will only be treated of 
here in a purely scientific manner. 

It is a great mistake to claim that among the majority of boys 
excessive indulgence in masturbation is very common, since the 
truth is that such is the exception rather than the rule. There are 
boys whose nervous system is not stable, and those who are pre- 
cocious in their mental processes, who like to seclude themselves 
very much from the games and sports of their comrades, and who, 
having indulged in self-abuse, keep up the bad habit until it pro- 
duces harmful results. But, as a rule, boys like to be up and 
doing, and each feels that he likes to stand as high in all pursuits 
of early life as his fellows. This generous rivalry tends to ele- 
vate the moral nature of the boy. Thus it is that a healthy 
moral status exists which tends to keep boys in the right path. 
If, perchance, a boy has indulged unnaturally, he, as a rule, sees 
the error of his ways, and he leaves off his bad habit, or indulges 
in it quite infrequently. Undoubtedly, in many cases the exag- 
gerated accounts of the ills which follow masturbation have a 
decidedly deterrent effect. While in the main the foregoing sur- 
vey of this subject holds good for the better classes of our com- 
munity, it must be confessed that among the poor and squalid, 
who are closely herded together, the moral tone is low and the 
habit is more wide-spread. 



MASTURBATION IN MALE SUBJECTS. 287 

In boarding-schools and reformatories it is said that masturba- 
tion is very common among the male subjects, but in the long run 
very few suffer from the habit. 

Masturbation has been observed in quite young children. In 
some cases there seems to be some nervous defect, of which sexual 
precocity is a prominent symptom. Then, again, phimosis, bala- 
nitis, adherent prepuce, congenital stricture, stone in the bladder, 
retained smegma, uncleanliness, dermatitis of all forms about the 
genitals, and thread-worms in the rectum cause erections, and thus 
the child contracts the bad habit. Stone in the bladder may also 
be the cause of sexual excitement in the infant. Then, again, it 
is not uncommon for nurses and care-takers to fondle and titillate 
the penis of the child in order to keep him quiet, and thus the 
bad habit is engrafted upon him. 

Epileptics, hydrocephalic infants, and those suffering from many 
forms of nervous disease, are said to be prone to commit mastur- 
bation. In older subjects, the victims of cerebral and spinal 
affections, masturbation is frequently a distressing symptom. 

As a rule, these subjects are seen to constantly handle their 
genitals and to produce erections, and they commit the self -abuse 
by peculiar movements of the thighs, by rubbing up against firm 
objects, or by rolling on their stomachs on the floor. 

It has been observed that flogging of young boys upon the back 
and buttocks has in many instances caused erection of the penis 
and ejaculation. This fact should act as a warning to both 
teachers and fathers. Many boys have been known to wilfully 
misbehave in order that they should be flogged upon the buttocks 
by young and pretty female school-teachers. 

Infantile onanists soon become sickly, flabby, peevish, and irri- 
table. Their gastro-intestinal functions become much impaired, 
and as a result their nutrition is much lowered. 

Young boys are either taught this bad habit by older boys or 
they acquire it by exploratory inquisitiveness. In many cases, 
particularly among boys approaching puberty, the morbid stimula- 
tion of the imagination by reading lewd books or by the inspection 
of lascivious pictures leads to more or less confirmed masturbation. 



288 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

Certain facts regarding masturbation have been very forcibly 
brought out by the late Dr. J. W. Howe 1 in the remarks now 
quoted : " There are certain gymnastic exercises provocative of 
masturbation. These exercises are common in all gymnasiums 
and in many school-grounds. My attention was first called to 
this subject by the history which a confirmed masturbator gave 
me of his first experiences. He entered school at the age of seven 
years. The day after his admission he visited the school gymna- 
sium. His attention was attracted to the swinging pole around 
which a number of boys were enjoying themselves. He took 
hold with the rest, sustaining the whole weight of the body by 
the hands, swinging himself around the circle for some time. In 
a few minutes he had such peculiar sensations about the genitals 
that he was forced to discontinue the movement, and rest. Again 
and again he swung himself around until he experienced the same 
effect, the sensations becoming more positive and intense. The 
next day, on trying the same experiment, the tingling sensations 
terminated in an orgasm. This led him to a closer examination of 
his organs, and also to new methods of increasing the same excite- 
ment, until finally he became a confirmed masturbator. 

" Another, a patient now under treatment, said that the first 
time he ever felt pleasurable sensations in his genitals was while 
he was engaged in sliding down the mast of a whale-boat. The 
first repetition of the exercise produced an orgasm, and from that 
grew the habit for which he was under treatment. A somewhat 
similar history has been given me by others, one a female, who 
learned the art by sliding down the stair-balusters. Lallemand 
relates the case of a boy who commenced masturbating by strad- 
dling down transverse bars, and another who excited himself 
while hanging by the arm, and thus sustaining the whole weight 
of the body." 

As a result of excessive unnatural indulgence these subjects 
lose their manliness, moral courage, and frankness of expression. 
They become secretive and seek seclusion rather than exercise and 

1 Excessive Venery, etc. New York, 1884, pp. 65 et seq. 



MASTURBATION IN MALE SUBJECTS. 289 

sports in the open air with their companions. In these cases the 
mind becomes centred on the genital organs, and the effect is to 
debase the moral standard. Some of these boys after a time be- 
come depressed in mind by the knowledge that they are victims 
of the indulgence in a secret habit. In perhaps the majority of 
instances, when the environments are favorable and the surround- 
ing influences are in the right direction, the bad habit is discon- 
tinued, and the whole morale of the boy undergoes a total change. 

It is very probable that the emissions which occur from mastur- 
bation have little, if any, lowering effect upon the general health 
of the subject. In very early years the ejaculate is simply pros- 
tatic and urethral follicular mucus, and its loss per se is not 
serious. Later on true semen may be emitted, but in most cases 
the amount lost at each indulgence is very small indeed, and most 
commonly it is simply the secretion of the seminal vesicles and of 
the ampullae. 

In exceptional cases the bad habit is persisted in, and then more 
or less serious mischief is produced. Probably 2 per cent, of all 
cases seen at venereal clinics are those of young men who suffer 
from the results of masturbation. The first and most obvious bad 
result of masturbation is lowering of the moral standard, as we 
have already seen. 

It is well to remember that in masturbators the normal sexual 
desire is absent, and the orgasm is produced by artificial friction 
and by brain-effort, which results from libidinous thoughts. The 
natural stimulants to sexual desire are also absent, and the act is, 
therefore, forced, unnatural, and abortive, and is very commonly 
followed by much temporary mental oppression and nervous agita- 
tion. 

It must also be borne in mind that this act is committed by 
boys when the sexual apparatus is in a state of growth and devel- 
opment and when the sexual centre has not yet been thoroughly 
developed by time and healthy processes. The growing prostate 
and the developing seminal vesicles and ampullae are thus acted 
upon by abnormal stimulation and by actual nervous shocks. 
This naturally explains why excessive and prolonged masturba- 

19 



290 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

tion in the young is more disastrous in its effects than it is in 
older subjects whose sexual organs have attained full develop- 
ment without damage during youth. 

The actual physical damage which results from masturbation 
occurs, therefore, in the sexual tract. The first morbid effect is 
hyperemia of the bulbous urethra, which is soon transformed into 
true catarrhal inflammation. This morbid state creeps backward 
and involves first the mucous membrane of the prostatic urethra, 
the verumontanum, and the sinus pocularis, and may attack the 
prostatic tubules in part or in totality. Then, in bad cases the 
morbid process extends through the ejaculatory ducts and attacks 
the ampullae and the seminal vesicles. Thus there is produced a 
low grade of catarrhal inflammation, which extends from the bulb 
backward to the seminal vesicles and tends to lower the tonus and 
resiliency of these parts. 

The mucous membrane becomes thickened and of a deep red 
and even purplish color, and from it a thick mucous secretion 
escapes. In some of these cases blood follows the onanistic act 
or is observed more or less constantly after urination. 

In somewhat exceptional cases of confirmed and inveterate 
masturbation, particularly in boys approaching or during puberty, 
the orgasm is produced not by manipulation by the hand, but by 
the introduction into the urethra as far down as the bulb or the 
prostatic urethra of some flexible instrument, which by titillation 
irritates the parts, particularly the verumontanum. The instru- 
ments used are sounds and bougies, pieces of wire bent so that 
they can be introduced, or pieces of white wax moulded in the 
form of bougies. 

In many cases there is more or less just complaint of relaxation 
and numbness or oversensitiveness of the scrotum and of a sense 
of softness of the testicles. Darkness of the skin of the penis, 
thickening of the mucous membrane of the prepuce, and density 
of the corpora cavernosa are found in many chronic masturbators. 

Then, again, the unnatural orgasms act as damaging shocks upon 
the nervous system, which then becomes deranged in its totality, 
and as a result the whole economy is more or less thrown into an 



MASTTJRBA TION IN MALE S UBJECTS. 291 

abnormal state. With the development of the lowered nervous 
condition, and as a result of the irritation transmitted backward 
from the prostatic urethra, veriunontanum, and prostate the integ- 
rity of the sexual centre is disturbed, and it is thrown into a con- 
dition of excitation and of decided irritability and incompetence. 
All these sexual and mental disturbances result in a vast array of 
morbid symptoms, physical and psychical. 

Many cases are on record in which the habit of masturbation 
is but one of the symptoms of men who are decidedly weak in 
their mental and moral conditions. As an instance of depravity, 
due to central nervous disorder, the following case 1 is very striking : 
The patient was a gentleman, twenty-two years old, who was seem- 
ingly healthy, but disposed to be taciturn and retiring in his 
habits. He came of perfectly healthy stock. One evening after 
a generous dinner he retired to his room and locked the door. 
His mother, anxious in consequence of his behavior when at the 
table, followed, and through the keyhole saw him, erect and fully 
dressed, engaged in the act of violent masturbation. This com- 
pleted, he threw himself on his bed in his clothes and slept. 
The mother informed the father of what she had seen, and there- 
after the young man was closely watched. 

Xine days afterward the patient left his friends at a picnic party 
in the woods, and this time the father followed him and witnessed 
the same scene as before. After returning home in the evening 
the parent sternly reprimanded his son for his misconduct, when 
the latter informed him that he was very miserable, that for more 
than a year he had been subject to attacks of a furious sort in 
which masturbation became an irresistible necessity. He begged 
his father's forgiveness and promised that w T hen he next had pre- 
monitions of his trouble he would inform his friends, who might 
then secure his hands behind his back. 

After dining a few days later he notified his father that he was 
about to be affected as before, and would soon be almost uncon- 
scious of what he was doing. His hands were immediately bound 

1 L'Annee Medicale Caen, Xo. 1, Tome ii. p. 7, December, 1876. 



292 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

firmly behind his back, when he was at once seized with a convul- 
sion that lasted for ten minutes. He fell to the ground, his respi- 
rations became accelerated, his face pallid and satyr-like. He 
also uttered hoarse cries in a strange voice. His father, thoroughly 
alarmed, hastened to liberate his son's hands, when the latter at 
once arose, and in the presence of both his parents proceeded to 
perform the act of masturbation in the most furious manner, 
without pausing an instant. This over, he burst into tears, and 
concluded by falling asleep as usual. 

This man had no sexual desire. The first intimation he would 
have of the attack would be an insupportable pain in the back 
part of the head, occurring sometimes an hour or two before, 
sometimes immediately after meals ; then there would be an erec- 
tion of the penis and unconsciousness of subsequent events, so 
that the presence of strangers presented no bar to the execution 
of the act. On one occasion of this sort, when observed by his 
physician, the latter describes his condition as very disgusting ; 
his face was pallid, his features distorted, and saliva escaped from 
his mouth. Under careful hygiene and symptomatic medication 
this man recovered. Leeches were regularly applied to his neck. 

A striking instance of periodical insanity with intense sexual 
impulse is worthy of brief mention. The father of the victim 
was a neuropathic and addicted to sexual excesses, who died of 
cerebral disease. The patient up to his twenty-ninth year was 
sexually normal. At that time he suffered from concussion of 
the brain due to a fall. After this accident every three or four 
months the man was seized with such an intense desire to mastur- 
bate that wherever he happened to be, and no matter who were 
present, he at once exposed his organ and frantically performed 
the act. The sight of women seemed to cause the morbid seizure. 
When the frenzy passed away he would become calm, regain his 
self-control, and sorrowfully regret the act. He was sent to an 
asylum for a time, but was later on discharged. This really was 
a case of exhibition insanity with intense sexual fervor. 1 

1 Krafft-Ebing : Psychopathia Sexualis. Stuttgart, 1891, pp. 298 et seq. 



MASTURBATION IN MALE SUBJECTS. 293 

Symptoms. In the first place, the function of urination is more 
or less impaired. Frequent micturition is very commonly com- 
plained of, and in many patients there is more or less mild incon- 
tinence or dribbling of urine after the act. In very bad cases 
such is the hyperemia of the mucous membrane of the bulbous 
and prostatic urethra that the passage of urine causes a severe 
scalding sensation (sometimes compared to the insertion of a hot 
iron in the canal), and toward the end of the act a more or less 
copious flow of blood. In some cases at the end of the act there 
is decided pain in the prostate, resulting from its physiological 
contraction. Examination of the affected portions of the urethra 
by means of the endoscope shows a thickened and inflamed con- 
dition of the mucous membrane, very often with marked swelling 
of the veruniontanum aud of the orifices of the sinus pocularis 
and of the ejaculatory ducts. In these cases the passage of goodly 
sized bougies a boule (24 to 30 French) causes great pain in the 
deep urethra, and very often a flow of blood. 

When the finger is introduced into the rectum and the pros- 
tate is carefully explored, it is usually found that this organ is 
in part or in whole swollen and sensitive, and that pressure upon 
it causes the escape of mucus from the urethra. (See pp. 240 
et seq.) If the examination is pushed further it may be dis- 
covered that the ampullae and seminal vesicles are tender and 
distended. 

As a result of these lesions of the sexual organs and of the 
nervous disturbances there is usually more or less impairment of 
the sexual function. Such patients, when attempting coitus, find 
that they are sexually weak, although they may have normal de- 
sire. Their erections are either absent or incomplete, or, if normal, 
they last but a short time. As a result, the power of intromission 
is more or less lost, and, when present, the performance of coitus 
ends in premature ejaculation. In some of these cases vigorous 
erections occur at times when the patient is not near a woman, 
but they fail utterly when in close proximity. 

Such cases form a large contingent of the class designated under 
the title symptomatic impotence. 



294 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

These patients are further tormented with nocturnal emissions, 
with or without erotic dreams, also with daytime pollutions, which 
mav follow defecation or urination, or be caused by muscular 
efforts, or by the simple presence of a woman. 

The ill-health which is developed in consequence of excessive 
masturbation may be expressed by the terms anaemia and neuras- 
thenia. Neurasthenic masturbators never cease complaining of 
all forms of morbid symptoms. The following list taken down 
verbatim as it was rattled off by the patient may serve as a good 
specimen of these wails. He said he suffered from insomnia, pain 
in the head (occipital and frontal), in the eyes, back, down legs 
and feet, and in the body ; felt nervous when he walked or 
worked ; was more tired in the morning than at night, and felt 
mentally depressed ; had frightened dreams at night ; his memory 
was failing ; had ringing of bells in his ears and palpitation of the 
heart on the least exertion, and often suffered from shortness of 
breath ; fever flashes at night, and then he feels hot and feverish ; 
has cold, clammy hands and feet ; gets very dizzy if anyone looks 
at him in both eyes, and has no appetite and is troubled with consti- 
pation. He wound up by claiming that he had very sensitive and 
also numb spots and blotches over the whole body. Many cases 
are much less severe and the patients only complain of a few 
symptoms. 

In more severe (and we may say desperate) cases the symptoms 
are more accentuated, the psychical condition is much worse, and 
marked hypochondriasis may develop. In some of these cases 
the mental condition of the patient is rendered infinitely worse 
by the persistency of the pollutions and the unceasing loss of 
erections and power of intromission. 

In some cases in which masturbation has been moderately in- 
dulged in, and in which no permanent harm has been done to the 
patient, the recollection of the early transgression may cause want 
of confidence and timidity in attempting coitus. In such a case, 
though there may be one or two preliminary failures, the patient 
should not be discouraged, since success will come by repetition, 
especially if warm encouragement is given by the surgeon. 



MASTUBBA TION IN MALE SUBJECTS. 295 

In later life the recollection of early indulgence in masturbation 
very often comes to a man's mind, and is wrongly considered the 
cause of sexual weakness, which is usually due to conditions 
which developed long afterward. 

Treatment. Infants addicted to masturbation should be treated 
on a mechanical basis — that is, such measures and appliances 
should be adopted as will prevent the child from touching his 
genitals. 

In young boys the indications are to break up the habit as 
soon as possible. To this end much careful watching is neces- 
sary, and reprimand and good counsel should be judiciously used. 
It is always well, when this habit is suspected, not to allow the 
patient to sleep with another boy. In such cases the boy should 
not be kept closely at his studies, but should be encouraged to in- 
terest himself in sports and games and out-door pastimes. It is 
not well to terrify these boys, since good, wholesome advice and 
kindly treatment, persuasion, and sympathy will do more toward 
breaking up the bad habit than fear and punishment will. In some 
bad cases, however, it may be necessary to apply every night an 
adjustable apparatus made out of tin or wire, like short drawers, 
which will cover over the genitals and buttocks and can be locked, 
so that the patient's hands cannot reach his penis. By this pro- 
cedure much benefit may be produced. 

In the cases of masturbators suffering from nervous, cerebral, 
and spinal diseases the central condition should receive most atten- 
tion. Such cases, however, are very rarely benefited by any form 
of treatment, either moral, coercive, pharmaceutical or mechanical. 

In some incorrigible cases of old and insane masturbators ex- 
cision of a portion of the nerves of the penis near the root of the 
organ may cause the cessation of the habit. Clark 1 reports the 
case of a man thus operated upon who was thereby much benefited. 

Boys at and beyond puberty usually are afflicted, as we have 
seen, with diseases of the sexual apparatus, and these should 
receive especial attention in the way of careful and continuous 
local treatment. 

1 Lancet, September 23, 1898. 



296 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

Peripheral irritation very often leads, as we have already seen, 
to more or less confirmed masturbation. When the patient is 
found to have phimosis he should be promptly circumcised. 
Adhesions of the prepuce and smegma retained in the preputial 
sac should receive proper surgical treatment in most cases, prefer- 
ence being given to circumcision. In the rather rare cases of 
congenital stricture of the urethra, internal urethrotomy should 
be performed. Erections caused by stone in the bladder call for 
proper surgical relief. 

By local treatment to the urethra and prostate much can be 
done for the relief of these patients. When the urethra is the 
seat of chronic congestion, irrigation with weak solutions of nitrate 
of silver, beginning with a strength of 1 to 10,000 and gradually 
increasing them to 1 to 5000 and 1 to 1000, will be very benefi- 
cial. When the irritability of the urethra has become less marked 
instillation of the silver salt, 1 to 500 to 1 to 250, may often be 
resorted to with excellent results. When the prostate has been 
affected it will be necessary to treat that condition according to the 
directions given on page 257. In many cases the occasional intro- 
duction of the cold steel sound will tend to allay urethral erethism. 

The indications for general methodical treatment in boys and 
men are, as far as possible, to restore the health and to improve 
the moral tone of the patient. Such drugs as have a decided tonic 
action should be given, such as iron, quinine, strychnine, phos- 
phorous preparations, arsenic, and perhaps the animal-extracts by 
injection. Bromide of potassium is sometimes beneficial when 
there is great erethism and to prevent pollutions. Belladonna, 
conium, gelsemium, cannabis indica, piscidia erythrina, antipyrin, 
and hyoscyamus may also be used in these conditions. Sea and 
mountain air, cold baths, healthy out-door sports should be advised, 
together with faradization and massage. 

Such patients should eat good, wholesome food without much 
spicing ; they should eat sparingly at night ; should sleep on a 
hard mattress, with light covering, and in a cool, well- ventilated 
room. They should retire when they are tired and sleepy, and 
get up as soon as they awake in the morning. 



CHAPTER XXII. 

SEXUAL EXCESSES AND SEXUAL ERETHISM. 

To sexual excesses much more harm to the economy is attributed 
than the facts of the case really warrant. In many cases sexual 
excesses are committed by persons who previously had suffered 
from the effects of masturbation, and then the consequences may 
be severe. 

Young men, particularly those newly married, are sometimes 
guilty of over-indulgence in coitus, and as a result they may be- 
come debilitated or perhaps neurasthenic. But in these cases the 
passion is spasmodic, and it generally ceases with the loss of 
strength. Then, as a rule, moderation in sexual matters is 
observed, and the condition of the health receives proper atten- 
tion, and in the end no permanent harm may be done to the 
system or the genital tract. The same remarks apply to over- 
indulgence in young unmarried men. 

• It is well to remember that sexual capacity varies greatly in 
different individuals, and that what would be excess in one person 
may be considered by another to be about the average of normal 
indulgence. 

As some men grow older they may indulge to excess sexually 
as well as with alcoholics, and as a result ill-health is induced. 
In these cases a general reform is usually followed by the resto- 
ration of health, if the patient is not also suffering from the 
physical effects of early masturbation. When, with the maturity 
of the man, the sexual apparatus and the nervous system are per- 
fectly healthy, he, as a rule, can undergo, without permanent 
damage, severe and prolonged sexual and alcoholic indulgence, 
provided these excesses do not extend over too long a period. 
In these cases nature often shows remarkable powers of recupera- 



298 SEXUAL DISORDERS OF THE MALE AND FEMALE 

tion, and unless she is too severely overwrought, she can, in time 
and by means of care on the part of the patient, efface the effects 
of over-indulgence. The truth of this statement will be obvious 
to those who have seen many such cases, in which it seems remark- 
able that a man can retain his health and virility in spite of pro- 
longed and excessive sexual and alcoholic indulgences. 

In those cases in which men thus put a strain upon nature year 
after year, as time goes on sexual weakness may develop, and 
beyond the fortieth or fiftieth year they may become partially or 
wholly impotent. But in these cases there are often other factors 
in the decay besides those just mentioned. Such men may lead 
irregular lives, they may also tax their nervous system by engross- 
ing projects and schemes which involve worry, doubt, and fear, so 
that in also every particular their course of life is unhygienic. It 
is natural, therefore, that in the resulting physical and mental 
unsoundness the sexual function should be more or less im- 
paired. 

Sexual excesses by means of bestial practices, especially coitus 
ab ore, in many instances lead to ill-health, and in some cases to 
general paresis. But in these cases, as a rule, too much promi- 
nence, I think, is attributed to the sexual errors, and other damaging 
factors are not fully considered. As a rule, men who thus over- 
indulge err in almost every direction of life. They are irregular 
in eating, drinking, and in going to bed ; sit up late in stuffy rooms, 
playing cards and drinking, and they do nothing whatever in the 
way of hygienic reparation. It can readily be seen that under such 
conditions sexual excesses may ultimately lead to the man's down- 
fall. But there is still another powerful factor at work in many of 
these cases — namely, chronic syphilis (in many cases there may 
be antecedent arterial or connective tissue degeneration in the 
brain and cord) — the influence of which should be thoroughly 
borne in mind. According to my observation, the nervous and 
general break-down of men which is commonly attributed to sexual 
excesses, and particularly to immoderate coitus ab ore, has, as pow- 
erful contributory factors, first, a general unhygienic mode of life ; 
second, alcoholic over-indulgence ; and, third, chronic syphilis. It 



SEXUAL EXCESSES AND SEXUAL ERETHISM. 299 

can readily be seen that excessive sexual strain in snch individuals 
will inevitably lead to mental and perhaps physical decay. 

Treatment. The first indication is to bring about a cessation 
of the excesses and then to establish a condition of normal sexual 
hygiene. The general health of the patient should be carefully 
looked into, and any morbid condition should be promptly cured. 
The surgeon should lay stress upon the avoidance of all sources 
of sexual excitement (lewd women and men, lascivious pictures, 
obscene books, etc.), and should pay particular attention to im- 
proving the morale of the patient. A careful and searching phys- 
ical examination should be made, and if any part of the sexual 
tract is found to be damaged it should receive careful topical treat- 
ment. Little can be done to cure men suffering from nervous 
decay from the causes just mentioned. 

SEXUAL ERETHISM. 

The intensity of sexual desire and passion varies markedly in 
different individuals. In some it is very moderate, in others it is 
more pronounced, while in a few it is very strong and enduring. 
In cold and moderate climates, as a rule, the sexual appetite is 
not excessively fervent, whereas in hot countries it is a constant 
and dominating force. As a rule, among Americans the sexual 
appetite is fairly well developed, and in the majority of cases it 
is held well under control. In some exceptional instances we find 
young men who are in a constant condition of sexual erethism, to 
such an extent that it impairs their usefulness in life. Thus, we 
occasionally meet with cases of young men who, when they asso- 
ciate with young women in business affairs and in social life, be- 
come so sexually excited that their condition is betrayed, or who 
from fear retire from such association. Some young men employed 
in shoe stores have been kuown to lose their heads when fitting 
shoes on ladies' feet ; and in other pursuits and businesses the asso- 
ciation of the sexes is often interfered with by the abnormal sexual 
erethism of the male. This rather abnormal state is not at all 
common in the female. 



300 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

Guelliot 1 reports a very interesting case of sexual erethism. It 
was that of a highly nervous man of twenty-three years of age. 
From his fifteenth year such was the excitability of his genitals 
that the least touch on the glans penis produced ejaculation. At 
the age of twenty-three this man had coitus eleven times in one 
afternoon without fatigue with a woman suffering from nympho- 
mania. It is stated that from that time on this man could undergo 
seven ejaculations a day. 

In many of the colored race such are their brutal licentiousness 
and the exaltation of their sexual appetite that negroes are con- 
stantly conniving at the commission of rape. 

I once saw a gentleman who suffered from persistent sexual 
erethism for years until he voided an oxalate of lime calculus from 
his prostatic urethra. 

We also see instances in which men beyond fifty or fifty-five 
years of age become the victims of an annoying sexual desire, 
and, strange to say, many of them are able to indulge in coitus 
with all the vigor and reserve force of a man of thirty. In all 
probability the irritative structural and degenerative changes 
which are taking place in the prostate are at the root of this 
senile sexual erethism. 

There is a class of cases of inordinate sexual desire in the 
male, to which attention was first directed by Beard, 2 which de- 
serves special mention. In the majority of these cases the sub- 
jects of this trouble are educated, intellectual, moral, and religious 
men, of exceeding sensitiveness of nature, most of whom shrink 
in horror at the contemplation of their condition. I have had a 
number of such cases under my care from time to time, but none 
of them gave such a graphic account of their condition as that 
presented by one of Beard's patients, which I will transcribe. 
Beard says : "A clergyman, aged forty years, came to my office, 
and, after long delay and marked hesitancy and confusion of 
manner, related substantially the following history : ' I am/ he 
said, i in a most lamentable, even desperate, condition. I fear 

1 Op. cit., p. 214. 2 Sexual Neurasthenia, pp. 273 et seq. 



SEXUAL EXCESSES AND SEXUAL ERETHISM. 301 

that my memory is deserting me, and that I bid fair to become 
both a mental and physical wreck.' He appeared healthy, and 
his mind, when directed from his trouble, was as vigorous as ever. 
He had been married but five years, and by mutual agreement, 
based on their ideas of personal purity and religion, and perhaps 
also on an almost complete lack of sexuality on the part of his 
wife, he had to a considerable degree suppressed sexual inclina- 
tions that were naturally very strong. He did not, however, be- 
come unbearably annoyed through these efforts of repression until 
some two years ago, when priapism would occur and continue for 
hours, diverting his mind from study and irresistibly directing his 
thoughts in such licentious channels that he became at times over- 
whelmed with anguish and despair. Intercourse brought only 
partial and temporary relief, and sometimes he would lie awake 
for hours, after a repetition of this natural effort for relief, with 
erections that would not subside. He was in constant fear that 
he would commit some act of folly when alone with certain of 
his female parishioners, and for this reason resorted to methods 
and excuses to avoid meeting them alone that he thought might 
seem to them strange and inexplicable. This worried him greatly 
also." This patient had been operated upon, without result, for 
redundant prepuce. He had mild hemorrhoids and varicocele. 
He was treated by good hygiene with bromides and bitter tonics, 
and assurances of recovery were held out to him. 

As a result of treatment he says : " I have a good, healthy 
imagination, almost free from voluptuous images. Again, instead 
of the unsatisfied burning desire for sexual intercourse which came 
again and again during the day and night, the desire is now very 
moderate and at times not perceptible. Instead of repeated erec- 
tions when alone, all seems comfortable and quiet. Only one of 
the symptoms I spoke of still remains, and that is the insane 
desire to take hold of women (who perhaps tempt me), to caress 
and fondle them, and play with them. The presence of certain 
women excites my passions, but by no means in the same manner 
as before. Please remember that I never took liberties with 
women in former years, and that I have not yielded to this de- 



302 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

sire, no matter how strongly tempted, yet I find it remains. My 
wife is a very chaste woman, and she regards my desire to fondle, 
look at, and admire her form as signs of manly weakness. She 
thinks yielding to these things only hurts me and excites my pas- 
sions. The desire to look at and fondle women is much stronger 
than the longing to have intercourse with them. If this terrible 
longing is clue to some disorder of my system, I want the physi- 
cian's help ; if it comes from a wicked heart, I'll fight it till the 
day of my death. You perhaps can help me to decide." In this 
case Beard says that good advice and the sedative effects of the 
bromides produced a cure. My own experience in these cases 
has taught me that in general there is some deep-seated trouble 
in the sexual tract, which has been caused by early and chronic 
masturbation (perhaps by chronic gonorrhoea) and by the conges- 
tion of the sexual parts which results from prolonged indulgence 
in libidinous thoughts and from dalliance with women without 
coitus. 

Treatment. In all cases a thorough examination of the patient 
should be made as to his general condition — mental and physical. 
Care should be taken that the general nervous system is improved 
by fresh air, healthy out-door exercise, cool bathing, change of air 
and scene if possible, and by the use of good, simple, nutritious 
food. A thorough examination of the genito-urinary tract should 
be made, and if any structural damage is discovered it should be 
treated on the general lines laid down for the management of 
chronic urethritis, prostatitis, and seminal vesiculitis. ( Vide 
supra.) Bromides and sedatives may produce temporary relief, 
but they can hardly be expected to cause a cure. 



CHAPTEE XXIII. 

SPEKMATOKKHCEA. 

In the light of our present knowledge of the morbid conditions 
of the prostate, deferential ampullations, and seminal vesicles, and 
chronic urethral inflammation, the subject termed spermatorrhoea 
can be lucidly elaborated in a few pages, whereas in the past, when 
the scope and exact nature of this symptom were not clearly 
known, many pages and even volumes were required to tell what 
we really did not know. In the past spermatorrhoea has been 
the bugbear alike to the layman and the surgeon, while to-day the 
term itself is a misnomer as applied to most cases, and when used 
in any connection it is unprecise and unscientific. 

As has already been shown in the chapters on Chronic Prosta- 
titis and on Masturbation, the abnormal discharges observed in 
cases belonging to these categories are, as a rule, not of seminal 
fluid, but of a morbid prostatic mucus with perhaps a few zoo- 
sperms. Patients who have masturbated excessively in youth, 
and who have damaged their prostates, ejaculatory ducts, and 
the seminal vesicles, fall into a condition of ill-health in which 
hypochondriasis and neurasthenia are prominent symptoms. The 
physical and moral tone of these individuals is very much low- 
ered ; their thoughts are centred on the genital organs during the 
day and they dream of erotic subjects at night. In this mild state 
of moral degradation the whole economy seems to go wrong, and 
such patients complain without ceasing of an infinitude of morbid 
symptoms. They talk and reason, as a rule, in a prolix and in- 
coherent manner, and are, day by day, thrown into a condition of 
panic by the escape of a small amount of prostatic mucus, which 
they speak of as seminal fluid, the loss of which they regard as so 
serious and so devitalizing to their health. Now, these cases may 
be summed up in the following way : First, young men who, as a 



304 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

result of masturbation and perhaps gonorrhoea, notice after urina- 
tion, defecation, or hard labor, and in their sleep, the escape of a 
fluid which comes from the prostate. Second, cases in the same 
condition, plus a little discharge, due to relaxation from chronic 
inflammation of the ejaculatory ducts, the ampullations, and the 
seminal vesicles. Third, older men, in whom gonorrhoea and 
sexual excesses have reacted on all the seminal parts, and who, 
spontaneously or in urination, or at stool, or in excesses, notice a 
quite copious secretion, which consists, in some cases, of prostatic 
mucus (see p. 248). and also of the secretions of the seminal vesicles 
and of the ampullations. In these three categories may be in- 
cluded all the cases to which the term spermatorrhoea may in any 
way be applied. As we shall see a little further on, more or less 
perfected seminal fluid may escape in some individuals, but the 
underlying conditions are not those of disease. The so-called 
pollutions and emissions of chronic masturbators are, as a rule, 
grossly exaggerated as to their copiousness and frequency of occur- 
rence. These patients come to the surgeon with a sorry story of 
the great extent of their seminal losses. The truth is that in 
most cases the morbid mucus which escapes during the day or 
night is very small in quantity. Sometimes it consists of only 
a few drops, and rarely, if ever, amounts to half a teaspoonful. 
The tendency to morbidly exaggerate these so-called seminal losses 
is so prevalent that the truth can hardly be obtained by the sur- 
geon. I have for several years investigated this subject under 
varying conditions of difficulty, and I have reached the conclusion 
already stated. 

To my mind, the terms defecation-spermatorrhoea and urination- 
spermatorrhoea are unscientific and unnecessary, and they do harm 
by reason of their ominous significance. The real facts are that 
certain mechanical conditions (the chief of which is abdominal 
pressure) cause a little morbid mucus to escape from a damaged 
prostate or in consequence of a relaxed condition of the seminal 
parts above. In like manner, I think that that ill-sounding term 
pollutions is a sort of a pathological scarecrow. These, for the 
time, unbalanced boys and men have in their prostates and deep 



SPERMATORRHEA. 305 

seminal parts a focus of irritation which may during sleep disturb 
the sexual centre, already in a condition of erethism, and this dis- 
turbance reacts in its turn badly on the unstable nervous system. 
The erotic dreams that are so much written and talked about are 
merely the result of a damaged sexual sphere and a general nervous 
depression. What is needed in the management of these cases is 
the recognition of the morbid condition of the sexual organs, and 
when a correct diagnosis of the case has been made there is no 
necessity for refinement and elaboration in the details of unpleasant 
symptoms the importance of which is always unduly magnified. 
Most of these cases are much troubled about their loss of man- 
hood (and quacks foster this idea), and they are really made worse 
by the perusal of the ordinary treatises on spermatorrhoea, with 
their unsavory symptom-complex. My experience has taught me 
that a great step is gained if by scientific methods we can demon- 
strate to these worried individuals that they are deceiving them- 
selves as to the quantity of morbid mucus lost, and that sperma- 
tozoa are not commonly found in it, and, if found, only in small 
quantities. 

With our more precise knowledge as to the nature of these 
cases, and our more practical methods of treating them, we shall, 
no doubt, as time goes on, see less chronicity of their course and 
very much less of the resulting mental depression and lowered 
health. 

Many continent men notice at times, owing to abdominal press- 
ure or severe exercise or straining, the escape of a mucoid fluid 
from the meatus. In many instances this secretion is simply 
prostatic mucus, and in others it comes from the ampullations and 
seminal vesicles. This condition is a very simple one, being only 
the partial removal of a plethora. When it occurs frequently it 
may, in nervous individuals, cause anxiety and dread, but it 
speedily ceases with the adoption of a rational sexual hygiene. 

A large amount of loose statement and exaggeration has been 
made regarding nocturnal pollutions and their supposedly disas- 
trous effects. The pollutions of young or older masturbators are, 
as we have seen, the complex outcome of sexual damage, and 

20 



306 SEXUAL DISORDERS OF THE MALE ALD FEMALE. 

spinal cord and general cerebral depression and weakness. Now, 
it is obvious that in healthy men these conditions do not exist, 
therefore the occurrence of an occasional emission is not followed 
by harmful results. According to my experience, most men who 
have these emissions seek and obtain the remedy in coitus. Some 
men, of a timid and nervous temperament, however, who have 
moral scruples, will not indulge in sexual intercourse, and, in 
somewhat exceptional cases, their genital centre becomes irritated 
and the general health lowered. These cases, however, are not 
very numerous, and by proper advice can be benefited and cured. 
It is impossible to say what number and what frequency of 
emissions may occur without damage to the individual, since some 
men are sexually vigorous and others are the reverse. I have 
known many men to have several emissions a week for a long 
time, and yet their health was not at all affected ; whereas in 
others I have seen one such discharge in a week, or ten days, or 
less, followed by mental depression and physical debility. When 
a man is mentally and physically strong and vigorous, and is up 
and about in a lively way, a few and perhaps many nightly ejacu- 
lations will do him no harm. But a weakly, neuropathic man 
with a worrying tendency, who shuns society and does not in- 
dulge in healthy exercise, may become much reduced. In these 
particular cases, however, the mind, by dwelling on the seminal 
loss and the portent of possible impotence, is the chief factor of 
ill-health. In all cases it is important to establish a wholesome 
state of sexual hygiene. 

IMAGINARY SPERMATORRHEA. 

Many young men who have indulged even moderately in mas- 
turbation imagine in subsequent years that, as a result of their 
former habit, they are then suffering from spermatorrhoea. This 
idea is mendaciously set forth in the pamphlets of and in personal 
interviews with advertising quacks, and it causes in many patients 
much worry and anxiety. Some of these patients have no symp- 
toms except those they conjure up in their minds, while in others 



SPERMATORRHOEA. 307 

some slight deviation from a normal condition is magnified into a 
serious evil. 

In most men in periods of sexual excitement a perfectly clear, 
viscid mucus escapes in small or large quantity from the meatus. 
It is the secretion of Cowper's glands and of the urethral fol- 
licles ; therefore, it is perfectly normal in every respect. After 
dalliance with women men notice this secretion, and some become 
much alarmed, as they think they are losing semen. In young 
and strong courting men (when the engagement is rather long 
and the mutual affection between lover and fianc&e is very intense) 
sexual excitement in the male is often so great, and this Cowper's 
gland secretion occurs so constantly and so copiously, that much 
disquietude of mind is felt by them. Some men even become 
hypochondriacal and neurasthenic. The trouble in these cases is 
that the excitement cannot be allayed by coitus. It cannot be too 
clearly understood that this condition is a perfectly harmless one, 
and that it will cease at once when marital relations are established. 
This condition is called urethorrhcea ex libidine. In some cases 
this secretion escapes during erections at night. 

Some patients, having recovered from gonorrhoea, may see for a 
time a little harmless, clear mucus within the meatus, and others 
who have not had gonorrhoea may see the same. They run to the 
surgeon, milk out with more or less firm squeezing a little secre- 
tion, and then look the picture of woe, and claim that they are 
losing their manhood. In other cases the declining and scanty 
gonorrhoeal secretion which escapes from the urethra, or the few 
threads which yet may be seen in the urine, are looked upon by 
many as loss of semen, and they are more or less unhappy. Dur- 
ing the condition of involution which occurs after the subsidence 
of congestion of the prostate a little harmless prostatic mucus 
may escape from the urethra, particularly after defecation, and 
this may by some be looked upon as a sign of evil omen. 

Nervous and worried patients bring to the surgeon specimens 
of urine which they erroneously think contain spermatozoa. 

Some overworked and neurotic young men who may not have 
a full, liberal diet, and who eat a preponderance of vegetables, 



308 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

not infrequently bring to the surgeon specimens of slightly acid 
urine of low specific gravity, which has a peculiar opaque color 
bordering on a milky tint. The constant passage of this phos- 
phatic urine, and perhaps the thought that in boyhood he had 
masturbated, result in convincing the patient that he is losing 
seminal fluid. Others become likewise worried about the presence 
of urates in their urine. Quacks find these individuals pliant and 
oft-returning victims. In these cases it is important for the sur- 
geon to remember that a condition of lowered health may exist, 
and that in some instances these patients are somewhat neuras- 
thenic. The most convincing evidence for such individuals is the 
addition in their presence of a little acetic acid to the urine, which, 
if it contains much earthy phosphates, is rapidly rendered clear, 
and if it also contains carbonates there is an additional marked 
effervescence. This little chemical test, together with wholesome 
advice and tonic treatment, will soon put these patients in a better 
state of mind, and then under favorable circumstances the health 
may be restored. 

Horseback-riding, cycling, and severe jolting may sometimes 
cause the escape of a little prostatic mucus or of the secretion of 
the seminal vesicles. In some cases the fluid seems to come from 
Cowper's glands. As a rule, these little discharges cause no worry 
to healthy and vigorous men ; but nervous, worrying, and neuras- 
thenic individuals may be very much troubled in mind. 



CHAPTEE XXIV. 

SEXUAL WORRY AND HYPOCHONDRIASIS AND SEXUAL 
NEURASTHENIA. 

SEXUAL WORRY. 

Many individuals become worried about the condition and 
the function of their genital apparatus, or of some part of it, 
while others become possessed of a groundless, morbid fear of 
some abnormal state or disease of these parts which does not 
really exist. In the majority of cases men or boys of average or 
marked intelligence, not knowing exactly what is normal, com- 
plain of simple, harmless conditions or of appearances which they 
think may lead to something more or less dangerous to the func- 
tion of the parts. As a rule, cases of this category are simply 
instances of sexual worry, which may be more or less acute and 
prolonged, but rarely present a formidable condition. On the 
other hand, some individuals become really sexually hypochon- 
driacal and fall into a morbid state of mind. 

In the category of sexual worry there is an infinitude of com- 
plaints. A man consults the surgeon because one testis hangs 
lower than the other, and he fears ill consequences may result. 
Another convinces himself that his penis is too small, or that his 
testes are ill developed, and that he may not be able to indulge in 
coitus. Such slight affections as simple red spots (perhaps microbic 
invasion) on the glans and scrotum sometimes send a man post- 
haste to the surgeon, thinking that something very bad has hap- 
pened. The normal redness of the meatus is not uncommonly 
the cause of much mental uneasiness. Then, again, the smegma, 
natural to the prepuce, may be regarded as an evidence of disease 
for which a man may anxiously seek treatment. One of the most 
persistent victims of sexual worry that I have ever seen was a 



310 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

robust young man in whose coronal sulcus a few little crypts, not 
as large as the head of a pin, caused by the invagination of the 
mucous membrane, were to be seen. Notwithstanding that the 
man was told impressively several times that his penis was in 
perfect condition, his worry caused him to come back a number 
of times a year for several years, in order to obtain fresh reassur- 
ance that he was all right. 

It sometimes happens that the coronal collar or expansion of 
the glans penis possesses a deeper hue than normal, even a deep 
red color, and that sometimes the part appears minutely papillated. 
I have several times had this condition shown to me by men in an 
anxious state of mind, and in some a deep-rooted fear of ulterior 
cancerous development was entertained. 

A phimotic condition of the prepuce, moderate or well devel- 
oped, is a not uncommon cause of worry, and mild or severe 
balanoposthitis has, in my experience, several times been the cause 
of much anguish of mind. 

Some men become worried because they find their scrotum 
studded with many little, harmless, unchangeable milia (those 
minute white papulations which are so common), and it was diffi- 
cult in some instances to comfort them. One man who had 
several small wens seated in the scrotal tissues was firmly con- 
vinced that his spermatogenic function was entirely out of order, 
and that these tumors were evidences of a vicarious activity which 
might lead to sterility. Notwithstanding the absurdity of this 
assumption, it required several interviews to convince the man 
that he had nothing but little harmless tumors. 

Some men come to the surgeon complaining that their meatus 
is unnatural ; in some, from their stand-point, its lips are too 
flaring and the orifice is too patulous ; in others the lips are natu- 
rally in close coaptation, and that must be wrong. I have seen 
many instances in which sensible men have worried over these 
absolutely normal conditions. 

Eczema and psoriasis of the penis very often induce a worried 
condition of mind, and much apprehension has been entertained 
by many regarding signs of eczema marginatum of the thighs, 



SEXUAL WORRY AND HYPOCHONDRIASIS. 31 1 

crural fold, and scrotum. Simple perspiration at the peno-scrotal 
angle and in the crural fold has caused many men to think that 
their sexual apparatus was entirely out of gear. 

Minute spots or patches of pigmentation about the genitals 
cause in the minds of some individuals much uneasiness, aud the 
discovery of small superficial nsevi of recent growth has sent the 
bearer to the surgeon in a condition of panic. 

Strange to say, the equanimity of patients suffering from hydro- 
cele, even when the tumor is large, is rarely even moderately dis- 
turbed ; whereas varicocele may cause such worry that a hypochon- 
driacal or neurasthenic condition may result. (See Chapter XX.) 

Strange as it may seem, many men, particularly young and 
healthy ones, become thoroughly convinced that they are suffer- 
ing or have suffered from gonorrhoea, although they have never 
presented any symptoms of that infection. These men are usually 
old masturbators or sensitive men who are continent for long 
periods. They express by diligent efforts a little clear mucus 
from the meatus, and offer that as undoubted evidence of the 
correctness of their statements. These patients very often assert 
that they experience vague, dull pains in the region of the pubis 
and in the course of the pendulous urethra. Pain at the end of 
the penis is also frequently complained of by them, and it causes 
them much worry. Such patients are prone to fall into the hands 
of quacks, who usually put them through a fearful ordeal in the 
way of cutting operations, sounds, and injections. I have seen 
several cases in which these patients had been under the care of 
regular but ignorant practitioners, who had proposed meatotomy 
and other wholly unnecessary and, to them, harmful procedures. 
If these patients are submitted to a careful urethral examination 
as well as a thorough examination of their urine, taken at different 
periods of the day, especially early in the morning, and they are 
found to be free from gonorrhoea, it is usually easy in one or two 
interviews to convince them that they are only the victims of 
sexual worry. In such cases moderate coitus regularly indulged 
in is very beneficial, and, as a result, these men soon cease to 
complain of pains in the genitals. 



312 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

Then, again, more or less pronounced worry may occur in cases 
of obstinate chronic urethritis. Such patients continually squeeze 
the glans penis from behind forward, to see whether they can pro- 
duce a drop of secretion. They are on the lookout, bright and 
early, for the morning drop, and they freely provide themselves 
with glass vessels, into which they frequently urinate and then 
critically examine for urethral threads. In some cases this worry 
is so prolonged that a mild neurasthenic condition is produced. 

Then, again, patients will come to the surgeon bringing speci- 
mens of urine laden with phosphates and carbonates or urates, 
and claim that their sexual and urinary apparatuses are seriously 
out of order. If by a strange coincidence there is present any 
of the foregoing harmless structural conditions, if there is more 
or less imaginary pain felt in the testes, scrotum, penis, or in- 
guinal or hypogastric region, the patient may fully convince him- 
self that his health is in a very critical condition. Many of 
these cases fall very readily into the hands of quacks, by whose 
ignorance and rapacity they are often greatly injured and cruelly 
despoiled. 

In all the foregoing cases the worry of mind results from some 
harmless condition or from some affection which is readily curable. 
The root of the trouble is that patients have gotten their minds 
fixed upon their genital organs, and for a time more or less con- 
stantly this thought dominates their existence. In many instances 
no effect on the health is produced ; in others the mental and 
physical vigor are somewhat impaired ; while in still others dys- 
pepsia, mild sleeplessness, and moderate cachexia may supervene. 
As a rule, however, all these cases can be relieved, ameliorated, 
or cured by sensible, kindly advice and encouragement or by 
well-directed treatment, local or systemic.^ 

SEXUAL HYPOCHONDRIASIS. 

In my experience true hypochondriasis, originating in some 
imaginary sexual disorder, is very rare. Perhaps the specialist 
in nervous diseases may see more of these cases than the genito- 
urinary surgeon does. In the cases I have seen the mental dis- 



SEXUAL WORRY AND HYPOCHONDRIASIS. 313 

turbance hinged on the early and vigorous practice of masturba- 
tion, on the memory of sexual excesses, or on the fixed thought 
that an antecedent gonorrhoea had never been cured. In some 
cases there was an abidingly haunting religious fear that in sexual 
indulgence and excesses an unpardonable sin had been committed. 
In somewhat rare cases in continent men nocturnal emissions have 
led to a markedly hypochondriacal state of mind. In these hypo- 
chondriacal cases morbid fears are not uncommonly a marked 
symptom. These patients are always in a state of excitement 
and worry about their digestive organs, in which they claim 
vague radiating pain or a dull heaviness is present ; about catch- 
ing cold, and the weak, distressed, and painful state of their lungs, 
and about the atony and cold sensations, or tingling and pricking 
feelings, which are experienced in their genital organs. They 
imagine they are going to suffer or are suffering from softening 
of the brain, paresis, locomotor ataxia, or any disease which they 
hear of. In their recital of their imaginary ailments they are 
tediously prolix, and frequently enter into details which are really 
disgusting. They are most exacting, sometimes exasperating, in 
their requirements of the surgeon, and at each interview insist 
that a thorough physical examination be made of nearly every 
organ of the body, as well as of the secretions. They are often 
hypersensitive, and imagine that they are the objects of ridicule 
on the part of friends and others. They can apply their minds 
to no useful purpose, and they are incapable of well-directed 
physical effort. 

SEXUAL NEURASTHENIA. 

The term sexual neurasthenia, or nervous prostration, is to-day 
widely employed in an indiscriminate manner as designating a 
large and heterogeneous class of cases in which there is more or 
less ill-health, together with some trouble, mild or severe, of the 
sexual apparatus. Too much latitude has been given to the use 
of this term, and very frequently the inquiry into the etiology of 
the cases designated as neurasthenic has been too superficial and 
of a routine character. There can be no doubt that certain sexual 



314 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

irregularities, excesses, and morbid states so weaken the nervous 
system that a serious condition of ill health is produced ; but, on 
the other hand, this identical morbid state may be induced by 
other causes, which in their turn more or less directly lead to 
sexual debility. 

Though the existence of neurasthenia as a definite morbid entity 
has been denied by some authorities, there can be no doubt that 
there exist many cases in which the symptoms of impairment of 
the nutrition of the nerve-centres and of their lowered function 
are sufficiently definite and common as to warrant the retention of 
this term in our nosology. While, therefore, neurasthenia cannot 
be called an absolutely well-defined disease, like diphtheria or 
tuberculosis, it may be considered a well-marked morbid condi- 
tion, having a wealth of symptoms which are tolerably constant, 
and most of which are present in the majority of cases. The 
fact of the matter is, that when one has become fully acquainted 
with this weakly and irritable condition of the whole nervous 
system, blended with anaemia and chlorosis, its recognition is 
usually very easy. 

The main causes of neurasthenia are severe mental and bodily 
strain and overwork, anxiety, worry, excitement, uncertainty of 
mind, and mental emotion of a depressing character. Certain mor- 
bid conditions, such as typhoid fever, malaria, syphilis, and influ- 
enza, may leave in their wake a state of the nervous system which 
this name properly expresses. In this condition the drain on the 
nervous system required by the vital processes is so great that there 
is not at any time a reserve supply of nerve-force to call upon ; 
hence it can readily be understood that sexual debility, inability, 
or apathy may soon develop. In this event, however, it is not 
correct to class such a case as one of sexual neurasthenia. The 
sexual debility is the result of the ill-health, and not its cause. On 
the other hand, sexual excesses, unnatural prolongation of coitus, 
buccal coitus, conjugal onanism, or withdrawal, masturbation 
(particularly in men at or near middle life, also in younger sub- 
jects), and long-continued sexual erethism with unsatisfied desire, 
not infrequently induce a condition of ill-health in which the 



SEXUAL WORRY AND HYPOCHONDRIASIS. 315 

classical symptoms of neurasthenia are present. Such cases, there- 
fore, reasonably come under the category of sexual neurasthenia. 

An important question in the etiology of neurasthenia now pre- 
sents itself for consideration. We quite commonly see young or 
middle-aged men who have chronic anterior and posterior gonor- 
rhoea, chronic prostatitis from masturbation or gonorrhoea, or 
chronic inflammation of the seminal vesicles and deferential 
ampullations, and even from imaginary or real rectal disease, 
who fall into such a condition of ill-health with mental unrest 
and debility which no other term than neurasthenia will concisely 
express. In these cases the condition of the sexual apparatus 
seems to be the dominating influence in the long morbid chain, 
and the condition is strikingly one of marked sexual disorder. 
The question then presents itself : Are these cases primarily due 
to irritation which is reflected from the morbid area back to the 
genital centre, and from there to the spinal cord and brain, in 
which it sets up a condition of malnutrition ? or are worry and 
morbid fears induced by the genital trouble the cause of the 
mental and physical decay ? These questions can only be par- 
tially answered by ingenious theories which may at will be elab- 
orated in support of either contention. Seeing that we have no 
pathological facts and observations to guide us, the more rational 
course, to my mind, is to wait until, little by little, definite and 
scientific knowledge is acquired upon this very obscure subject. 1 
One practical point, however, here suggests itself — namely, that 
in most of these cases relief of the local trouble is promptly 
followed by improvement of the mental and physical health of 
the patient. Such cases are typical instances of sexual neuras- 
thenia. 

1 The result of researches of Hodge (Journal of Morphology, 1892, vol. vi. p. 
95) are very interesting as tending to throw some light on the pathology of neu- 
rasthenia. This observer found that prolonged electrical stimulation and fatigue 
produced in the brain-centres of certain animals and birds marked degenerative 
changes in the nuclei, cell- protoplasm, and cell- wall when present. These 
changes disappeared slowly under rest and quiet, and after a lapse of time the 
normal structure of the parts was re-established. Perhaps in neurasthenia the 
molecular nerve-changes are the underlying pathological causes. 



316 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

Symptoms. The onset of sexual neurasthenia is usually slow 
and insidious. The most common symptom is a dull, heavy feel- 
ing in the head (frontal or occipital), sometimes with a sense of 
constriction, which is worse in the morning. Such a patient, after 
a troubled night, awakes, unrefreshed, in very much the state of 
a man who had indulged to excess in alcohol the night before. 
Then the appetite becomes capricious, and it may be nearly lost. 
The digestive functions become labored and slow, and constipation 
is apt to result. At this time a marked change in the morale of 
the man can be noted. He is indisposed to perform his work, 
and has to force himself to keep up to his duties. His mind is 
less acute, his memory less accurate and may become very defec- 
tive, and his disposition becomes altered. He angers easily, and 
any slight cause irritates and worries him. Troubles of any kind 
which in the normal state would be soon thrown off are brooded 
over, and severe mental depression may follow. Then sleep be- 
comes much more disturbed and unpleasant, and perhaps erotic 
dreams keep the patient in a restless state during the night. In 
the day the discomfort of the patient is very great by reason of 
the weakness, the mental unrest, and the torpidity of the gastro- 
intestinal processes. In a short time the facies of the sufferer 
becomes much altered. A pallor with a dull, worried expression 
is often very noticeable, together with some or much emaciation 
of the face. In some cases these patients soon come to look like 
sickly or weakly old men. General loss of weight soon becomes 
noticeable and adds another source of worry to the patient's 
mind. 

The foregoing description applies to very bad cases, and must 
not be considered as absolutely typical. Thus we see cases in which 
men seem to be a little anaemic or run down ; others as if they 
were somewhat overworked, or too much confined in-doors, or who 
do not have sufficient sleep. In none of the cases can the patient, 
from his appearance, be said to be really sick. Then, again, we 
see men who appear well-nourished, and who have a fairly good 
color in their faces, who surprise us by their wealth of neuras- 
thenic symptoms. As a rule, however, the man carries in his 



SEXUAL WORRY AND HYPOCHONDRIASIS. 317 

face the stigmata of a nervous system the nutrition of which is 
very considerably impaired. 

The tale of woe which sexual neurasthenics pour into the sur- 
geon's ears or those of anyone else who will listen to them is 
almost endless and of infinite detail and variety. They complain 
of vertigo, of dull pains in the head, spine, back, and legs, and 
insist that they have painful areas all over the body, especially 
over the trunk. They are graphic in their descriptions as to how 
hot and cold flashes dash and radiate all over the body, and as to 
the acnteness of certain pricking or itching sensations or of a feel- 
ing as if water were flowing over their limbs. They also complain 
of cold feet and hands, which, when felt, present a disagreeable, 
clammy sensation. They perspire on slight exertion, suffer from 
local hyperidroses, and sometimes from a profuse general sweating 
which exhausts them greatly. In the recital of their cardiac and 
lung troubles they are very diffuse and insistent. They sometimes 
have a dull, heavy precordial sensation, with a sense of suffoca- 
tion and sometimes of pain, reminding one of angina pectoris. 
Palpitations of the heart, with a frequent, thin, wiry, and irregular 
pulse, can very often be found by the surgeon. These patients 
sometimes claim that they suffer severely in their lungs. They 
somewhat uncommonly are attacked by such a sense of suffocation 
that asthma is simulated (asthma sexuale). I have seen several 
cases in which there was much emaciation, and in which the 
patients so pertinaciously insisted that they had severe pains in the 
lungs and cough, together with night-sweats, that a suspicion of tu- 
berculosis was for a time entertained. As Gray 1 pertinently says of 
these cases,. the " prolonged nervous depression diminishes the good 
sense and increases the bad judgment and lack of self-control." 

In considering the foregoing rich but sad symptomatology, in 
which the peace of mind and the health of the patient are so seri- 
ously disturbed, it can be readily seen that the victim is incapable 
of applying himself to any work, bodily or mental, and that all 
the enjoyments of life are lost to him. He becomes irritable and 

1 Medical News, December 16, 1899, pp. 788 et seq. 



318 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

excitable, and is anything but an agreeable companion. To the 
surgeon he is often a sore trial, and in his importunities for relief 
he taxes his patience and endurance to the utmost. In some bad 
cases I have observed an abiding spirit of marked ingratitude, 
notwithstanding the sufferers had received much kindly and patient 
attention, together with proper advice and treatment. Their ail- 
ments and sufferings and demands for relief are always poured 
forth into the surgeon's ears, and no attention is paid to his good 
offices previously extended. 

The attempt has been made in the foregoing description to de- 
pict the severer class of cases of sexual neurasthenia. It must 
be remembered, however, that this disordered condition of the 
nervous system varies in different individuals. In some it is 
mild, and only a few of the clinical symptoms are present ; in 
others the condition is more severe and the symptom-complex 
greater, while in the very severe cases the whole economy seems 
to be deranged. 

The local or sexual symptoms are numerous, and have their 
origin in some part of the sexual tract. In some cases, when ill- 
health brings back memories of early masturbation and the patient 
begins to brood over the imaginary ill consequences or the sinful- 
ness of the act, sexual symptoms seem to spring up as if by magic. 
Neuralgia of the testis, or a heavy, distended condition of these 
glands, is complained of. Darting or dull, heavy pains in the 
scrotum, groins, and urethra are said to be frequent and severe. 
The penis, testicles, and bladder seem to have lost their life, and 
desire for coitus is more or less blunted. These patients complain 
that their genitals are cold or clammy or wet, and that they are 
certain that these organs are growing small or are withering up. 
Prostatic and bladder pains are also complained of. Coitus not 
being indulged in, emissions, mostly nocturnal, with or without 
erections, occur and become the source of great worry. Any 
escape of mucus from the urethra is looked upon as a dangerous 
omen, and convinces the patient that he is becoming devitalized. 
In the cases where there is tangible lesion of the sexual tract there 
may be a chronic urethral discharge, especially in the morning. 



SEXUAL WORRY AND HYPOCHONDRIASIS. 31 9 

There may be increased frequency in urination, and exceptionally 
post-mictional hematuria, pain in the glans penis at the end of the 
act, pain or burning sensations in the urethra and perineum, and 
deep in the pelvis from involvement of the ampullations of the 
vasa deferentia and seminal vesicles, or the pain may be referred 
to the rectum itself. (For further information on these subjects 
the reader is referred to the chapters on Masturbation, on Chronic 
Posterior Urethritis, Chronic Affections of the Prostate, and 
Inflammation of the Seminal Vesicles and of the Deferential 
Ampullations.) 

Diagnosis. In sexual neurasthenia the disorder in the sexual 
apparatus so dominates the patient's mind that if the surgeon is 
sufficiently familiar with the trouble he can readily make a diag- 
nosis. In all cases it is very important to make one's mind per- 
fectly clear as to whether the general morbid state had its origin 
in some imaginary or real sexual disorder, or whether in neuras- 
thenia the man's mind became disordered as to the condition of 
his sexual apparatus and its function. When the sexual tract is 
the seat of morbid change a thorough, painstaking investigation 
should be instituted, in order to determine the location of the 
trouble as well as its nature, extent, and severity. Upon the 
accuracy and fulness of this investigation the intelligent treat- 
ment of the case and its outcome largely depend. 

I have seen several cases of sexual neurasthenia in which the 
symptom-complex seemed to point to the existence of the opium- 
habit or cocaine-habit or to secret chronic alcoholism. 

Prognosis. In sexual neurasthenia, as a rule, a good prognosis 
may be given, since the disease, though chronic, does not lead to 
death. Such is the markedly beneficial effect produced on the 
mind by the relief of symptoms and the cure of morbid sexual 
conditions that the patient's health in general becomes appreciably 
better at once. In some neuropathic and hypochondriacal cases, 
and in some patients with an inherited unstable nervous system, 
sexual neurasthenia may be very persistent, and a long period of 
time — months or years — may elapse before a cure is brought 
about. Such cases, however, are not very common, and recovery 



320 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

in most instances occurs in a few months or in less than a year. 
The return to vigorous health may be slow. 

Treatment. In sexual neurasthenia, as we have seen, the 
morale of the patient is most improved when he experiences ame- 
lioration of his local symptoms. With this fact in mind, the 
surgeon should enter upon a mild and conservative course of 
treatment directed to the part of the urethral canal which is 
affected. It is important that heroic measures or new fads should 
not be used in these cases, and that exacerbation of the underly- 
ing chronic inflammation of the parts should not be induced. 
The patient watches the progress of the case with such tireless 
scrutiny, and is so easily depressed if matters do not run smoothly, 
that we cannot be too careful in the use of topical applications 
or of instruments. Very often these patients are importunate, and 
try to bully the surgeon into a change of treatment or to the 
adoption of more stimulatiug applications. The course to pursue 
in such an event is to placate as far as possible, but not to resort 
to measures of doubtful value or those which may do even mod- 
erate harm. 

The general management of a Case requires much care and cir- 
cumspection. The condition, disposition, and surroundings of the 
patient must be fully studied ; then-^ careful and grateful system 
of hygiene should be established. The patient should be kept 
quiet and at rest, and all cares and anxieties and obligations should, 
as much as possible, be kept from him. The condition of the 
stomach and bowels should receive much attention, and, if neces- 
sary, medication to aid digestion and prevent constipation should 
be sparingly administered. Pepsin, peptenzyme, bismuth, nux 
vomica, rhubarb and soda, pancrobilin pills, and mild aperients 
should be kept in mind and used as the occasion seems to demand. 
The food should be simple, bland, and nutritious, and should never 
be taken in too large quantities. Milk in abundance, if assimi- 
lated, is excellent, as also are rare red meats in moderation, with 
stale bread, rice, and hominy. Tea, coffee, and cocoa are, as a 
rule, harmful, and are liable to disagree with the patient or to 
make him more nervous. 



SEXUAL WORRY AND HYPOCHONDRIASIS. 321 

The condition of the kings and of the heart should be carefully- 
watched and treated symptomatically. In all cases, however, 
drugs should be used sparingly, and their action should, as a rule, 
be regarded as secondary to the general system of management of 
the case. It is well to bear in mind strychnine, arsenic, iron, 
quinine, cocoa, preparations of phosphorus, and the hypophos- 
phites ; but never to use them in a careless and routine manner. 
Alcoholic liquors in general are not beneficial, but a mild claret or 
Burgundy, or some pale ale or beer, may at times, chiefly at meals, 
be of benefit if taken in limited quantity. The use of tobacco 
should be reduced to a minimum, and cigarette-smoking should 
be firmly interdicted. 

In some cases the bromides, cautiously administered, have a 
very sedative effect. Much care should be exercised if a prepa- 
ration of opium is used, lest addiction to the drug should be in- 
duced. Antipyrine, phenacetin, trional, and all heart-depressants 
should only be employed at certain urgent times. 

It is well to keep these patients at rest and to aim at tranquillity 
of life. As pointed out by Gray, 1 it is seldom necessary to put 
patients to bed for three to six weeks, as was at first proposed. 
As a rule, it will suffice to keep them there ten or twelve hours 
out of the twenty-four, and to have them avoid fatigue when they 
are up. 

Sexual neurasthenics brood over their trouble so much, if left 
alone, that it is well that they should have mental diversion and 
that one or two compatible and companionable people should be 
with them. Bathing is of much beuefit, particularly at the sea- 
shore, but care should be exercised that the temperature of the 
water be not too low. Then, again, fresh-water baths should 
not, as a rule, be too hot. Sponging the body and mild rubbing 
down with a rough towel are very beneficial. The faradic cur- 
rent (the slowly interrupted form) may produce good effects if 
administered in short daily seances. Massage carefully r adminis- 
tered for short periods once or twice a day usually leads to seda- 

1 Loc. cit. 
21 



322 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

tion, and, later on, invigoration ; but it must be remembered that 
in some cases patients are really made worse, hence it is necessary 
to use caution in this procedure. Change of scene and of air is 
of the highest importance in these cases. Sea voyages, short or 
protracted, restful quiet in the mountains or in some pleasant 
country place, and camping out, offer sources of much relief, and 
often lead to marvellous improvement. 

It is well to remember that very pronounced anaemic patients 
need careful feeding with nitrogenized matter in the form of raw 
beef cut up finely or of well-made beef -tea. 



CHAPTEE XXV. 

COITUS EESERVATUS VEL INTERRUPTUS ; WITHDRAWAL, 
OR CONJUGAL ONANISM. 

A not infrequent cause of ill-health and of well-marked neu- 
rasthenia, particularly in the male in youth and in middle age, 
but also in the female, is that unnatural method of coitus which 
among us is called conjugal onanism, or withdrawal, and by Ger- 
mans, coitus reservatus vel inter ruptus. This harmful practice is 
mostly followed by well-to-do, refined, and educated people, and 
there is medical evidence at hand to prove that it is a rather 
widely spread custom, both in the married and the unmarried. 

The main object of this mode of coitus is to prevent concep- 
tion, and beyond that there are many underlying reasons and 
purposes. In some cases it is done without the woman's consent, 
and she, in her simplicity, thinks the method is proper. Between 
some men and women the arrangement for this procedure is de- 
liberately made, while in some cases the man wishes it, and in 
others it is followed at the woman's instigation. The underlying 
motives are various : the wife or husband may not desire chil- 
dren ; the wife may fear that pregnancy will spoil her beauty or 
ruin her good figure, or she may wish to avoid conception in order 
that she may not be removed from society's pleasures and obliga- 
tions or from the various functions into which many women enter 
with much zeal and enthusiasm, such as church and parochial 
duties, charitable objects, literary and scientific clubs, bicycle 
practice, etc. Then, again, painful and dangerous parturition, 
puerperal fever, puerperal eclampsia, post-partum dementia, and 
the ill-health of the wife are the reasons why pregnancy is often 
feared and unnaturally avoided ; and, further, in illegitimate 
coitus the fear of conception causes the adoption of this procedure, 
which also may be followed for economical reasons. In many 



324 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

cases the absence of the fear of conception leads to too frequent 
coitus. 

Most persons have no knowledge whatever of the harmfulness 
of this procedure. 

It would be rash to say that this bad habit is invariably detri- 
mental to the health of the man or the woman, since there is 
abundant evidence to prove that many men and women practice 
withdrawal for long periods without any perceptible discomfort or 
resulting deterioration of the health. Indeed, there is the widest 
variation in the effects of the habit. In some men it induces ill- 
health very promptly in a few months, or a year or more, while 
in others the practice may extend over several or many years before 
its baneful effects begin to show themselves. 

The resulting harmful effects of withdrawal may be summed up 
under the head of neurasthenia, which varies very much in severity 
and duration in different cases. A perusal of three of my cases 
will give a good general idea of the harmful results of this practice. 

Case I. A man, aged twenty-nine, of excellent physical and 
nervous condition, and with no previous damage to his sexual 
system, had practised coitus reservatus with his wife for three 
years. He then began to lose flesh, and became pallid, suffered 
from mild dyspepsia and constipation, and was restless, irritable, 
and despondent for trifling reasons. In this way he remained for 
nearly a year, the various symptoms gradually becoming more 
pronounced. A sea voyage, a sojourn in Switzerland, and gen- 
eral tonic treatment, together with baths and electricity, produced 
scarcely any benefit. In my examination of this man I learned 
his sexual history. Under a general invigorating regimen, with 
the use of tonics and with sexual rest, this man became perfectly 
well in about two months. 

Several years after he again fell into his bad habit, and experi- 
enced a mild relapse of his former symptoms. This time he was 
cured by sexual rest and out-door life in the mountains. After 
both sicknesses there was decided sexual impotence, which in 
each instance gradually ceased and left the man in a perfectly 
virile condition. 



CONJUGAL ONANISM. 325 

Case II. A man, aged forty-two years, had in general enjoyed 
good health and was not in the least neuropathic. He had suf- 
fered at puberty from pollutions induced by masturbation, and 
when thirty-two years old had suffered from chronic posterior 
urethritis. When thirty-six years old he married a strongly 
built, passionate young woman, and had with her practised with- 
drawal for six years. About five years after the commencement 
of this unnatural coitus he began to observe that his health was 
breaking down. He had been under the care of a number of 
physicians for about a year when he came to me. He then was 
thin, pallid, and sallow, and had an anxious facies. He com- 
plained of a multitude of ailments with incessant volubility. He 
slept badly, had bad dreams (sometimes erotic), awoke in the 
morning with a dull, heavy head, pain over the eyes, and much 
vertigo. As the day wore on these symptoms became less marked. 
He was generally depressed in mind, and sometimes decidedly 
melancholic. His memory was very defective, and so great was 
the physical and mental inertia that he could not attend to busi- 
ness or fix his mind for any length of time on a subject. There 
were general well-marked torpor of the stomach and intestines ; 
frequent urination, with pain in the prostate at the end of the 
act ; deep-seated pelvic pain, tenderness in the perineum, and a 
burning sensation at the anus were the symptoms referable to his 
sexual apparatus. His erections were weak, his ejaculations were 
feeble, and after difficult defecation a mass of mucus and pus 
escaped from the urethra. Examination showed that the poste- 
rior urethra was chronically inflamed and exquisitely tender, and 
that his prostate was much swollen in all tangible directions, and 
very sensitive to slight pressure, after which manipulation a 
worm-like plug of glairy, gray mucus escaped from the meatus. 

As a result of well-regulated sexual hygiene and local treatment 
to the prostate and posterior urethra this man's health improved 
surprisingly, and he became in a few months perfectly well in all 
respects. In this case tonics and sea bathing acted as valuable 
adjuvants to the treatment of what at the start seemed a very 
unpromising case. 



326 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

Case III. A man, aged thirty-two, of fairly good physical 
structure, but whose nervous system was never vigorous, had 
suffered in early years from pollutions following long-continued 
masturbation, which he began when twelve years old. He recov- 
ered from the morbid condition and remained in good general and 
sexual health for several years. When thirty years old he in- 
dulged freely in coitus reservatus with an amorous mistress. In 
about a year he noticed that his health was impaired, and he 
sought relief in taking all kinds of tonics, with no perceptible 
effect. When he came to me he presented a sorry appearance. 
He was pale, emaciated, and haggard, and his symptoms were 
legion. Utter weakness, loss of sleep, mental depression, lack of 
memory, gastro-intestinal inertia, palpitations, and profuse sweat- 
ing at slight cause were the principal symptoms. He complained 
bitterly of great and paroxysmal oppression to his breath, with a 
dry cough and vague pains in his lungs. He was very nervous 
and the subject of an abiding unrest. He had pains in his head, 
all down the spine from the occiput to the sacrum, had a sense of 
constriction around the abdomen, painful spots over the thorax, 
and there was decided paresthesia of the legs and forearms. On 
several occasions he had had attacks of severe cardialgia, which 
caused him much anxiety. He had imagined that he was suffer- 
ing from pulmonary tuberculosis, or from incipient locomotor 
ataxia or paresis, and had consulted men experienced in lung- 
troubles, who found those organs healthy, aud neurologists, who 
said that he was neurasthenic. Carefully directed treatment had 
failed to give him any relief. The recital of this exuberant 
symptom-complex convinced me that the man was suffering from 
the effects of coitus reservatus. This suspicion was confirmed 
by the patient, after much fencing and hesitation, on my exam- 
ination. 

Discontinuance of the bad habit, and the establishment of 
proper sexual relations, together with change of air and tonics, 
did much to improve this man at once. His convalescence, how- 
ever, was slow and sometimes halting, but to-day he is free from 
his symptoms and may be called a well man. Further transgres- 



CONJUGAL ONANISM. 327 

sions, even for a limited time, would probably throw him back into 
his former condition. 

These cases give a quite clear idea of the average run of mild 
and severe forms of this morbid state which are not of very fre- 
quent occurrence. 

At the risk of some slight repetition of what has already been 
said in the chapter on sexual neurasthenia, owing to the great im- 
portance of clearly understanding the effects of this bad habit, the 
category of its resulting morbid symptoms will be further dilated 
upon. 

As a rule, the onset of this trouble is slow and insidious with- 
out any dominating symptom or symptoms pointing to the origin 
of the trouble. In the main, the early symptoms most commonly 
observed are weakness, more or less loss of flesh, and pallor, 
nervousness, irritability, unrest, dyspepsia, and constipation, to- 
gether with a dull, heavy sensation in the head, likened by many 
patients to the feelings experienced after alcoholic indulgence. 
These bad symptoms are worse in the morning, and in a measure 
wear off as the day progresses. In general the nervous debility 
and ill-humor increase, insomnia becomes persistent, and the 
patient becomes irritable at the slightest cause, despondent, 
morose, melancholy, and even monomaniacal. There are often 
observed failure of memory and such an apathetic condition of 
mind that the slightest exertion is shrunk from. In most cases 
there is lack of sexual vigor, and there may be even decided im- 
potence. The performance of the sexual act is followed by much 
weakness and nervousness, together with a sleepy tendency in- 
stead of the normal vigor and alertness of mind. 

In some cases nocturnal erections, erotic dreams, and pollutions 
are observed, particularly in those whose sexual apparatus has 
been damaged by excessive coitus, masturbation, or gonorrhoea. 

The wearing-out of the nervous system which obtains in these 
cases shows itself in a large number of morbid phenomena. In 
addition to the many head-symptoms already mentioned, in vari- 
ous cases we find evidence of faulty innervation in the cardialgia, 
palpitations, and rapid and small pulse, which are so frequent ; 



328 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

in the shortness of breath and sense of suffocation (the so-called 
asthma sexuale), which are such prominent, but not common 
features ; in the spinal pain, general or local (spinal irritation) ; 
in the painful spots and joints ; in the numbness and the various 
paresthesia? ; in the sense of constriction, resembling girdle-pain ; 
in the excessive sweating, local or general, on very slight exer- 
tion ; in the nervous contraction of the larynx and oesophagus, 
and in the general gastro-intestinal inertia. The symptoms refer- 
able to the sexual sphere may be slightly marked or obtrusively 
prominent ; in mild cases, in which there has been no previous 
sexual disorder, there may be simply an uneasy sensation in the 
penis — a feeling of moisture — together, perhaps, with relaxation 
of the scrotum. Neuralgia of the testes is not uncommon, and 
the pain may be dull, heavy, or aching, or lancinating, or there 
may only be present a sense of distress and fulness in these glands. 

In one of Peyer's 1 cases the pain in the testes was so severe that 
when it came on the man had to go to bed or lie down on the 
spot on which he stood when he was attacked. There is also 
pain, deep and circumscribed, in the pelvis, in the groins, and in 
the lumbar and sacral regions, which is more or less constant. 
In some cases aching and burning pains are experienced in the 
perineum and anus. There may also be increased frequency in 
urination, with pain in the act, especially at its end, and in the 
glans penis. In some cases mild hematuria has been observed. 

In some cases there is a more or less constant state of erethism 
of the genitals, which has the effect of producing a desire for 
frequent coitus. 

In nearly all cases erections are less firm and enduring than in 
the normal state, ejaculations are less vigorous, the seminal fluid 
generally escaping in a feeble stream or by drops. 

The morbid effects of this unnatural mode of coitus produce in 
some women (but not in the majority) a condition of ill-health in 
which general debility, anemia, and neurasthenia are the chief 
features. As a rule, women are not so profoundly affected as 
men are. 

1 Der Unvollstandige Beischlaf, etc., Stuttgart, 1890. 



CONJUGAL ONANISM. 329 

In young women of poor fibre and of neuropathic tendency 
withdrawal in coitus and precipitate ejaculation on the part of 
their male consorts sometimes give rise to distressing heart-symp- 
toms. The evil effect of the incompleted sexual act may show 
itself simply in severe palpitation, which begins at once after the 
act and ends in a few minutes or several hours afterward. As 
the case grows worse the irritability of the heart becomes more 
distressing and is continually present. Then these women become 
depressed and irritable and very emotional. They suffer from 
headache, indigestion, constipation, weakness, and vertigo, and 
very frequently they have fainting spells. Though the pulse is 
weak, soft, and accelerated, and not infrequently intermittent and 
arhythmic, auscultation will reveal no structural lesion either in 
the heart or in the vessels. All these morbid phenomena quickly 
disappear when the bad habit is avoided and normal intercourse 
is indulged in. Tonics and good general hygiene are valuable 
adjuvants in the management of these cases. On this subject 
Kisch, 1 of Prague, has recently published an interesting essay. 

A general consideration of what takes place in coitus reservatus 
is now necessary in order that we may better understand the phys- 
ical and psychical damage wrought by this habit. The excitation 
of both man and woman is in a great measure under restraint. 
What should be absolutely spontaneous and untrammelled in the 
way of desire and sensation becomes abnormal by reason of the 
mental process by which the act is interfered with at its most 
critical stage. On this point the words of Eulenberg 2 are really 
graphic. He says : " The natural energetic sexual act experiences 
from the beginning an essentially artificial change. The attention 
directed toward the postponement and prevention of the natural 
intra vaginal ejaculation introduces an altogether heterogeneous 
arbitrary element in the process, which necessarily retards and 

1 Herzbeschwerden der Frauen verursacht durch den Cohabitation- act. 
Miinchen. med. Wochenschr., 1897, Band xliv. p. 617. 

2 Ueber Coitus Keservatus als Ursache sexualer Neurasthenie bei Mannern. 
Internat. Centralbl. fur die Physiol, und Path, der Harn und Sexual-Organe 
1893, Band iv. pp. 3 et seq. 



330 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

harms the proper working of the automatic reflex mechanism. 
The slower and less energetic friction, the weaker sexual feeling, 
and the less complete and sudden dissolution of the sexual ten- 
sion prevent the occurrence of such complete reaction as results 
from the natural ejaculation, by which, on account of the neces- 
sary energetic muscular action, a sudden emptying of the engorged 
bloodvessels of the genital apparatus results. The centripetal 
stimulus is set at naught, and through the disappearance of the 
central innervation the entire genital apparatus becomes suddenly 
and completely relaxed." In any case this act is most unsatis- 
factory both to the man and the woman, neither of whom experi- 
ences the complacency of mind and the gratification which usually 
follow the proper performance of the sexual function. 

It naturally follows from what has already been said that, in 
addition to the general condition of ill-health induced, coitus 
reservatus leads to more or less damage of the sexual apparatus. 
When a man has not previously suffered from chronic gonorrhoea 
or from the effects of masturbation, this bad habit produces a low 
grade of inflammation in the bulb of the urethra, in the posterior 
urethra, and in the prostatic follicles, and it may extend further 
and involve the ejaculatory ducts, the deferential ampullations, 
and the seminal vesicles. In any case an irritable, flabby, and 
atonic condition is induced which is unfavorable to the proper 
performance of coitus. When any of the above-mentioned 
parts has previously been the seat of chronic gonorrheal inflam- 
mation, with its submucous infiltration and mucous membrane 
catarrhal condition, an intensification of the process is naturally 
induced. 

We have, then, besides a damaged mind and body, a local and 
often deep-seated morbid state of the sexual apparatus. 

In forming an estimate of these cases it is necessary to take 
into consideration the general bodily and mental condition of the 
patient, the condition of the genital apparatus, and the habits, 
obligations, and surroundings of the patient. Further, we must 
ascertain how long the habit has existed, and how frequently the 
sexual act has been performed. It is most important of all to 



CONJUGAL ONANISM. 331 

determine the mental calibre of the patient, whether he is of a 
neuropathic tendency, either acquired or hereditary. 

There can be no doubt, as maintained by Peyer, that the results 
of coitus interruptus are variable, and that very many practice it 
without experiencing bad results. Some particularly strong . men 
(mentally and physically) can with impunity indulge in normal 
coitus once or more daily for many years ; others reach their limit 
with one or two indulgences a week, and still others cannot attain 
that degree of frequency without suffering from bodily or mental 
fatigue. In some cases of coitus interruptus a strong, well-bal- 
anced nervous system is largely responsible for the immunity 
which so many men enjoy. In many cases worry, mental excite- 
ment, and various dyscrasise are factors in the general break-down 
of health. Ignorance of the baneful effects of this habit on the 
part of some patients, and feelings of modesty or shame in others, 
are the two principal causes of the difficulty of diagnosis of coitus 
reservatus. When, however, the attention of the profession is 
prominently directed to this habit and its symptom-complex is 
generally understood, inquiries directed to its existence will be 
adopted, and the truth will in all probability be revealed. Much 
difficulty is sometimes experienced in getting a true history from 
a patient, and the surgeon must exercise prudence and tact, and 
he must call to his aid all his acumen. Parenthetically, I may 
remark that several patients have bitterly resented the mock, re- 
ligious, and sentimental interrogatories and admonitions to which 
they had been subjected by some surgeons. Several patients have 
remarked to me that they have gone for medical and surgical aid, 
and not for platitudinous moralizing. 

There is one point which should always be borne in mind — 
namely, that most of these patients suffer from some or many 
symptoms referable to the sexual apparatus, and that inquiry 
directed to these parts may reveal the existence of this bad habit. 
Therefore, it is necessary to examine the morning urine for the 
presence of various tissue-elements, to carefully explore the 
urethra, especially its prostatic portion, and by digital examina- 
tion in the rectum to ascertain the condition of the prostate, and, 



332 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

if possible, that of the deferential ampliations and of the seminal 
vesicles. 

Treatment. In the mild form of ill-health, simple discontinu- 
ance of the habit may produce a prompt and encouraging effect, 
and general hygiene and tonics may also be of very much benefit. 

In all cases, when necessary, proper and efficient treatment 
should be directed to the underlying urethral or seminal lesion, 
wherever it may be. 

Relaxation from business cares, rest, and change of air are of 
much value. Tonics, nutritious diet, carefully regulated, not ex- 
cessive, muscular exercise (gymnastics, bicycle, golf, walking, etc.) 
should also be ordered as the indications of the case may point. 
Electricity in some cases produces good results. 

Whatever method of treatment is employed, it must be remem- 
bered that no benefit will result until the sexual life of the patient 
has been brought back to its normal condition and until the integ- 
rity of his sexual apparatus has been restored. 



CHAPTER XXVI. 

PEIAPISM. 

While in the normal state erections last only a short time, in 
certain morbid conditions they are, on the contrary, of prolonged 
duration, and constitute a condition to which the term priapism is 
applied. 

In cases of true priapism the erections are painful, persistent, 
and irreducible, and are unaccompanied by sexual desire. Much 
latitude has been accorded to the term priapism, since under it 
have been classed several orders of cases which really are only in- 
stances of slightly prolonged and moderately painful erection, due 
to an obvious cause. 

Conforming to usage, however, we may divide this affection 
into the following classes : 

1. Priapism observed in infants and children, induced by reflex 
action in cases of long, tight, adherent prepuce, of stone in the 
bladder or prostatic urethra, and of worms in the rectum. 

2. Priapism in adult subjects, symptomatic of stone in the blad- 
der, stone in the prostatic urethra, stricture, cystitis, and observed 
during retention. In these cases the uneasy or painful sensation 
is felt in the glans penis, while the body of the organ usually is 
only moderately congested and sometimes curved downward or 
laterally. This condition disappears upon removal of the cause. 

3. Priapism symptomatic of gonorrhoea, with perhaps involve- 
ment of the corpus spongiosum and downward curvature. This 
condition is painful and transitory, and may occur several times 
during the night. In cases of downward curvature of the penis, 
due to inflammatory engorgement of the corpus spongiosum and 
spasm of the musculature of the urethra, the term chordee is 
applied. 



334 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

4. Priapism due to ingestion of cantharides, which is a form 
that is seldom or never seen now, since this drug is so rarely used 
in medicine. 

5. Essential priapism. 

It is unnecessary here to consider the first four forms of so-called 
priapism, as it is merely an intercurrent symptom, usually of short 
duration, of well-known morbid or structural conditions, and, as a 
rule, is relieved by operation or medical treatment. 

An attentive study of all reported cases, amplified by a consid- 
erable personal experience, has convinced me that we may divide 
essential priapism into four varieties : 

1. Priapism caused by injury to the spinal cord (either high 
up or low down), and by blows or violence inflicted upon the 
perineum ; 

2. Priapism which is a symptom of cerebral or descending 
spinal-cord disease ; 

3. Priapism which occurs after alcoholic and sexual excesses ; 

4. Priapism which attacks a person in ill-health, in whom it is 
difficult to obtain data as to local injury and causation, and in which 
cases there is now a tendency to look upon leukaemia as the etio- 
logical factor. 

Priapism after Spinal Injury. 

In this form of priapism the traumatism has been found as 
high up as the cervical and as low down as the lumbar and sacral 
regions. When the injury is in the cervical region it is probable 
that irritation of the nerves which pass down the cord to the 
sexual centre is the cause of the trouble, and that the priapism 
is due to excitation communicated to the erigentes. When the 
damage is inflicted low down it is probable that the sexual centre 
is so irritated that it is thrown into a state of chronic excitation, 
which shows itself in the engorgement of the penis. In these 
cases, as a rule, there is not great distention of the organ, nor are 
the attendant symptoms of a marked character. Such patients 
usually complain little of the condition of the penis, and they 
have no sexual desire. 



PRIAPISM. 335 

The course of these cases depends upon the extent and severity 
of the injury ; in some the integrity of the parts is restored and 
the priapism ceases ; in others death occurs sooner or later. 

Hunt 1 thinks that in the cases of traumatism of the spinal 
column and cord in which priapism is a symptom there has been 
injury to the sympathetic ganglia and nerves. He reports a case 
in which this lesion was found after death. 

Priapism in Cerebral and Descending Spinal Disease. 

The recorded cases of this variety of priapism are very few, and 
in most neurological writings this symptom is not much dwelt 
upon. In a case reported by Legros Clark 2 the patient, aged thirty, 
had suffered with hemicrania, during the violence of which he had 
several attacks of priapism. He also had pain in the lower part 
of the back, and in time became delirious, was attacked by epi- 
lepsy, became dull and stupid, and died in coma. After death 
the liver and spleen were found to be enlarged, and there was 
congestion of the base of the brain. It is unfortunate that a 
minute microscopical examination of the brain and cord were not 
made in this case. 

In Harwood's case 3 the man was twenty-eight years old, and 
was free from any disease. Following exposure to cold he had 
priapism and pains in his back, which gradually extended down 
his legs. He then complained of pain in the perineum and of a 
sensation as if he had a belt around his body. He died of cere- 
bral symptoms, the priapism having lasted one hundred and six- 
teen days. 

In this class belongs a peculiarly interesting case reported by 
Dukeman. 4 It was that of a man, aged thirty-five years, a fakir, 
who from early life had been a pronounced sexual pervert. He 
was anaemic, seemed to be laboring under severe mental depression, 



1 Medical News, February 25, 1882. 

2 St. Thomas' Hospital Eeports, 1887, N. S., vol. xvi. pp. 19 et seq. 

3 International Journal of Surgery, 1889, vol. ii. p. 7. 

4 Pacific Medical Journal, 1889, vol. xxxii. pp. 480 et seq. 



336 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

and practised hypnotism, in which art he was tolerably successful. 
No traces of spinal lesion could be found. For several years in 
the attacks, varying in duration between two and five months, this 
man suffered from priapism. He died of tuberculosis. 

I have had two cases of spinal syphilis in which there were 
inco-ordination of the movement of the legs, girdle pain, and 
hyperesthesia of the integument of the abdomen and back, in 
which mild priapism was a symptom, and which were cured by 
antisyphilitic treatment. 

In the cases of locomotor ataxia and of sclerosis of the poste- 
rior columns of the cord in which priapism is observed the symp- 
tom usually lasts during the early or middle stages, and ceases in 
the later periods. 

Starr 1 reported the case of an ill-developed male, aged twenty- 
one years, who had lateral curvature of the spine and meningo- 
myelitis, who suffered from mild priapism for seven years. 

Priapism Due to Sexual and Alcoholic Excess. 

The greater number of cases of priapism may be denominated 
alcoholic-erotic cases, since the trouble usually has its origin in a 
drunken sexual debauch. As a rule, the greater number of those 
who suffer from this form are young and vigorous men, although 
medical annals show that men in middle and advanced life fur- 
nish a moderate contingent. 

The mode of onset of erotic priapism differs. In some cases 
there is for a time increased frequency of erections, which are 
premonitory and last a few or many minutes ; in others, after 
sexual intercourse, the rigidity of the penis remains and becomes 
persistent ; while in still others the patient, on awakening from 
his debauch, finds that he is suffering from priapism. In most 
cases when the opportunity exists, these patients endeavor to re- 
lieve themselves by coitus, and they always fail. In exceptional 
cases orgasm and emission, without pleasurable sensations, occur ; 

1 New York Medical Journal, June 15, 1887, p. 75. 



PRIAPISM. 337 

but, as a rule, there is no sexual desire, and ejaculation is not pro- 
duced. In fact, it is stated that in several cases the suffering of 
the patient was materially increased. 

During attacks of priapism the state of the penis has been 
found to present several variations in different cases. In its most 
severe form the organ becomes much enlarged, tense, and com- 
parable to cartilage in rigidity, and the seat of severe pain. The 
glans may be double in size, much distended, and glistening, as 
if it would burst. The corpora cavernosa are very dense and 
unyielding to pressure in their whole length, including their 
crura. The corpus spongiosum is likewise hard and swollen, 
and its bulbous expansion is in a similar condition. 

In some cases the perineal muscles can be felt as dense fibrous 
bands, and the dorsal vein of the penis seems much distended and 
feels like a whipcord. 

In many of these cases attentive examination reveals very pain- 
ful spots or perhaps nodules in the corpora cavernosa, particularly 
toward their root or in the crura. Then, again, digital pressure 
on the bulb and over the perineal muscles may cause an agony 
of pain. Spasm of the cremaster muscles may be present, and the 
testes then are drawn forcibly up to the internal ring. This 
symptom may be wanting. In some cases there is pain in the 
lower part of the back and along the course of the spermatic 
cords. Redness and swelling of the prepuce may be observed as 
complications. As a rule, the integument of the penis retains its 
normal color. In this pronounced condition the sufferings of the 
patient are very severe, and many authors apply the term atro- 
cious to the pain which is seated in the virile organ. The patients 
fear the least touch of their linen or of the bedclothes, and jarring 
of the bed or heavy steps in the room cause them agonizing suf- 
fering. They draw up their legs upon the abdomen, in order to 
protect the penis from the slightest touch. This organ may lie 
rigid against the abdomen, or it may be more or less erect and at a 
right angle with the body in the horizontal position. Very soon 
these patients become much worried and apprehensive, and their 
faces give evidence of anxiety and suffering. In these cases urina- 

22 



338 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

tiou may be accomplished either "with little difficulty, or the act 
may be painful, slow, and halting, with a small, sputtering stream, 
or the patient may have to assume the knee-elbow position in order 
to expel the urine from the bladder. 

The atrociously painful symptoms are usually spasmodic in char- 
acter, but the attacks may be very frequent and much prolonged, 
in which event insomnia, nervous exhaustion, and general prostra- 
tion supervene. In this way the man suffers from day to day, 
sometimes experiencing very little amelioration of his condition 
for days or weeks. In many cases, however, there are intervals 
of comparative freedom from suffering, in which the hyperes- 
thesia and turgidity of the organ are somewhat diminished and 
the patient may have some much-needed sleep. 

The duration of severe priapism may be from two or three 
to six consecutive weeks, and even longer. In a hospital case 
observed by Birkett 1 it lasted five months. 

There is usually no fever, particularly in young, robust men, 
but in older subjects having leukaemia or visceral lesions pyrexia 
may be observed. 

In contrast to the foregoing very severe forms of priapism we 
observe cases in which the organ is less tense and distended, and 
in which the mental and physical suffering is not very severe. 
In somewhat exceptional cases the patients suffer but little pain, 
and the discomfort experienced in the turgidity of the organ is 
the chief symptom. 

It is not the rule to find priapism involving the corpora cavern- 
osa and corpus spongiosum at the same time. Some cases have 
been observed in which the glans and the whole corpus spongio- 
sum have been lax and extensile j others in which the turgescence 
of one cavernous body was very severe, while its mate was more 
supple, and others, again, in which the rigidity was unequally felt 
in the length of the corpora cavernosa. 

While, as a rule, the invasion of this trouble is prompt, even 
sudden, and severe, its involution is always slow and often halt- 
ing, and attended with disheartening relapses. The first sign of 

1 Lancet, 1867, vol. i. p. 207. 



PRIAPISM. 339 

improvement is the diminished rigidity of the organ, which soon 
becomes less painful, and thus the case progresses until the normal 
state is reached. . In that happy event the patient cannot be said 
to be entirely out of danger, for the reason that recurrences may 
follow at short or long intervals, particularly if the patient is 
guilty of sexual or alcoholic indulgence or excess, is subjected to 
wet or cold, or is constrained to undergo severe bodily exertion. 

From the records of the various published cases, the inference 
seems to be warranted that in about one-half of the cases the 
patient is left impotent. It would be unwise, however, to state 
this as a rule or law, since the publication of cases usually fol- 
lows quite promptly upon their occurrence. It may be that per- 
manent impotence is induced, or the condition may be of tempo- 
rary duration. In young and vigorous men it is to be presumed 
that their virility will later on be re-established. 

Etiology. While the etiology of this form of priapism cannot 
be clearly stated, certain suggestions may be made as to its causa- 
tion. In some cases there is strong evidence that damage has been 
done to the corpora cavernosa, particularly near their roots. This 
is shown in the tender spots and the hard nodules left after invo- 
lution of the affection. Then, again, in some cases there is a 
probability of blood extravasation into the areolae of the cavernous 
tissue. Whether or not in these alcoholico-erotic cases there has 
been irritation of the sexual centre and of the nervi erigentes, 
or whether there has been injury to the sympathetic nerve, we 
cannot say. 

A number of cases have been reported in Avhich it was clear 
that priapism was caused by injury of the penis and perineum, 
notably that of Johnson Smith. 1 In all probability traumatism, 
though unrecognized, is the essential cause in all cases. 

Priapism of Leukemic Origin (?) 

There is a class of cases of priapism in young men, but particu- 
larly in men of middle and advanced life, in which, during and 

1 Lancet, June 7, 1873, p. 804. 



340 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

after a more or less prolonged period of ill-health, this symptom 
appears. 

The clinical history of this form is similar to that already por- 
trayed, but in general there is an absence of any data as to excesses 
of any kind. In this form we find cases with the pronounced 
agonizing group of symptoms and cases in which lesser degrees 
of priapism and suffering have been experienced. In these cases 
there is a history either of neurasthenia, mental worry and de- 
pression, or of malarial fever and leukaemia, sciatica, hemicrania, 
and numbness and cramps in the muscles. 

Owing to the fact that leukemic blood-changes and enlargement 
of the liver and spleen have been observed in most of these cases, 
some authors unhesitatingly accept leukaemia as the cause of the 
priapism, although Peabody, 1 who leans to this view, makes the 
guarded statement that "it may be regarded as an occasional 
symptom of leucocythaemia " (leukaemia). While I am not pre- 
pared to deny that priapism may be etiologically related to leu- 
kaemia, I am free to confess that on the evidence thus far submitted 
this relation is in no manner made clear, and the suspicion forces 
itself upon one's mind that perhaps the occurrence was a coinci- 
dence. The trouble with the reported cases is that the antecedent 
history of the patient has not been thoroughly gone into. 

The facts have not been established that there has been no 
alcoholic or sexual indulgence, or in some cases that injury to the 
penis has not occurred. Having the leukaemic explanation in 
mind, this thought seems to have guided the various authors in 
their estimate and treatment of the case, and they have failed to 
pursue channels of investigation which might reveal some local 
injury to the sexual tract. Therefore, while I am not disposed 

1 New York Medical Journal, 1880, vol. xxxi. pp. 463 et seq., and ibid.-, 1881, 
vol. xxxii. pp. 272 et seq. See also Klemme, Schmidt's Jahrbucher, vol. cxxxi. 
pp. 173 et seq.; Edes, Boston Medical and Surgical Journal, July 27, 1871; Lon- 
guet, Progres Medical, 1875, Tome ii. pp. 447 et seq.; Matthias, Allg. med.Cent.- 
Ztg., 1876, Band xlv. pp. 1185 et seq.; Neidhart, ibid., 1876, Band xlv. pp. 681 
et seq.; Salzer, Berliner klinische Wochenschrift, 1879, Band xvi. pp. 152 et seq., 
and Wetherell, Medical Record, 1 880, vol. xviii. p. 192. 



PRIAPISM. 341 

to deny that this morbid blood condition may participate in the 
development of this chronic turgescence of the penis, I hold to 
the opinion that this etiology should not be fully accepted, but 
that inquiry in all cases should be pushed into the sexual ante- 
cedents of the patient, with a view of finding out whether there 
had been sexual excess or whether any part of the sexual sphere 
had been damaged. I can hardly understand why in some excep- 
tional cases the genital centre and the nervi erigentes have been 
thrown into a condition of severe and chronic excitation simply 
from general blood changes without there being some lesion of the 
parts under the control of or near to these nervous organs. 

In general, the facts concerning the troubles can be readily 
elicited from boys and young men, but middle-aged and old men 
are for various reasons less communicative as to their sexual habits 
and life. 

Prognosis. Few definite statements can be made as to the 
prognosis of priapism of any form. In those cases in which in- 
jury to the corpora cavernosa or thrombosis can be made out, 
incisions may greatly expedite the cure. The existence of spinal 
disease necessitates a guarded prognosis. In very much run-down 
neurasthenic subjects, in sexual perverts, and in those suffering 
from leukaemia the chances are that the priapism will be very 
persistent, and when it disappears that it will be very liable to 
undergo relapse. 

Treatment. In surveying the results of treatment of the cases 
of priapism already published one is forced to the opinion that 
nothing like a routine method can be laid down. Eemedies 
which have produced more or less good in one man's hands have 
failed in those of another. This much, however, can be stated 
with emphasis : Chloroform narcosis has failed in every case in 
which it has been used ; ice usually does more harm than good ; 
electricity has no value, and may even be harmful ; and leeches, 
to the number of sixteen and forty, have failed to produce any 
amelioration in the condition of the penis, and have been inju- 
rious in their depletory effects. 

My own preference, after a review of this whole subject, is to 



342 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

resort early to moderate and tentative incisions into the most 
turgid part, or into parts the seat of continuous pain, or into 
nodular masses, in all probability the result of traumatism. The 
parts should be carefully prepared for operation and thorough 
antisepsis should be employed. With a clean, incised wound we 
need not have the scarring, nodulation, or loss of the tissues of 
the cavernous bodies which almost always occurred in former 
years. 

Vorster 1 reports a case in which, after priapism had resisted 
various methods of treatment for thirty-two days, a cure followed 
four days after incision. 

In Booth's 2 case, after six weeks of vain effort in relieving the 
patient, five-gramme doses of the iodide of potassium four times 
a day gave immediate relief and caused the disappearance of the 
priapism in two weeks. In Matthias' case a similar good result 
followed the use of this remedy, and in W. H. Taylor's 3 case cure 
was produced by the combination of a mercuric salt with iodide 
of potassium. My own opinion is that it is always good practice 
in priapism to use either the potassium salt alone or in combina- 
tion with mercury when a history of antecedent or present syph- 
ilis is elicited. 

Bromide of potassium, chloral, belladonna, and morphine may 
be of benefit, especially during paroxysms ; lupuline, camphor, 
and cannabis indica have been used with indifferent results, and 
the same may be said of ergot and strychnine. 

Of local applications, the following may be found to be benefi- 
cial : hot baths, hot and cold spinal douches, sponging with very 
hot water, spinal cauterization, anodyne poultices (belladonna, 
stramonium, opium, hyoscyamus, and camphor), and perhaps, in 
some cases, ice-bags, but the latter must be guardedly used. 

Any ephemeral or systemic disorder should receive appropriate 
medication. 

1 Deut. Ztschr. fur Chir., 1887-88, Band xxvii. pp. 173 et seq. 

2 Lancet, 1887, vol. i. p. 978. 

8 Maryland Medical Journal, 1883-1884, vol. iv. p. 854. 



CHAPTER XXVII. 

SEXUAL PERVEESIOX. 

In the whole field of medicine there is no more melancholy 
chapter to peruse than that which treats of those degenerates who 
are victims of sexual perversion. This subject has of late been 
exploited ad nauseam, and by reason of their prurient details cer- 
tain psychological volumes on this morbid state have done much 
harm. I shall here only give a general outline of the various 
divisions of this subject. 

Sadism is the association of sexual lust with cruelty and vio- 
lence of varying degrees (biting, scratching, infliction of pain, 
infliction of injury and wounds, and even death). The sadistic 
act is inflicted either during or after coitus, or with the view of 
stimulating the declining sexual power. Lust-murder, or anthro- 
pophagy, is the severest form of sadism, and its perpetrator may 
not only kill his victim, but also eat a part of her. In some indi- 
viduals the sadistic crime is the equivalent of coitus. In this 
revolting category are included the cases in which coitus is indulged 
in with corpses (which might also be more or less mutilated), and 
those of men who can only have sexual intercourse when the live 
woman is laid out as a corpse with all funereal accessories. 

The mildest form of sadism is that in which a man has an 
orgasm when he surreptitiously cuts the hair of young girls, which 
he keeps as a sexual fetich. Under this division may be included 
the cases of individuals who have orgasms when they whip boys 
on the naked nates or when they see cruelty inflicted on animals. 

Sadism is very infrequently observed in women. 

In all probability vitriol-throwers are sadists. 

Masochism may be defined as the desire for abuse and humilia- 
tion as a means of sexual satisfaction. In cases of this form of 
perversion the individual seeks every opportunity to be beaten or 



344 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

injured by a woman. Such patients become sexually excited by 
any blow, or by direct injury, by flagellation, and by being trodden 
upon by women who have their shoes on. 

Fetichism is the association of lust with the idea of certain 
portions of the female person, or with certain articles of feminine 
attire, without which the performance of coitus is impossible. The 
inanimate sexual fetiches are handkerchiefs, shoes, stockings, 
gloves, beads, letters, locks of hair, articles of female underwear, 
and flowers belonging to some woman whom the pervert loves or 
has sexual passion for. 

The parts of the female body which have been selected as 
fetiches by these perverts are the eyes, the hand, and the foot. 
In their thoughts interest is concentrated on these parts, and not 
upon the genitalia. In some cases the fetich may be a cross-eyed 
woman or one with the amputated stump of one leg. Cases have 
been reported in which men were impotent unless the woman 
presented these abnormalities or defects. 

Mild cases of this form of trouble are really instances of 
psychical impotence. 

Hair-despoilers may be examples of the sadists and fetichists 
combined, since in the act of cutting they have a sexual orgasm, 
and the stolen tresses afterward act as stimulants to sexual lust. 

A mild form of fetichism is found in those individuals who are 
only sexually excited by a brunette and those to whom only a 
blonde is congenial. In this same category may be included the 
cases of men who, in order to become sexually excited, must see 
women dressed in a peculiar manner or have upon them some 
article which has taken the fancy (furs, velvet, silks, and feathers). 

Homo-sexuality is that form of perversion in which the sexual 
feeling for the opposite sex is diminished or absent, and in which 
sexual desire is centred on one of the same sex. Thus men 
become enamoured of certain men, and women of certain favored 
ones of their own sex. 

Urnings are certain homo-sexual individuals who have in their 
sexual life the same feelings as those experienced by normal sub- 
jects in hetero-sexual love. 



SEXUAL PERVERSION. 345 

Krafft-Ebing says of these cases : " The liming loves and 
deifies the male object of his affection just as a man idealizes the 
woman he loves. He is capable of the greatest sacrifices for him, 
and experiences the pangs of the unfortunate often unrequited 
love ; suffers from the unfaithfulness of the beloved object, and 
is subject to jealousy/' etc. " The attention of the male-loving 
man is given only to male dancers, actors, athletes, statues," etc. 

Effemination and viraginity are forms of the perversion known 
as urnings. In the male the subject likes to masquerade as a 
female. He seeks to make of himself by sweetness, sympathy, 
taste for aesthetics, etc., a fit mate for his homo-sexual lover. He 
endeavors to present a feminine appearance in gait, attitude, dress, 
and mode of speech. 

The female urmng in early life tries in every way to act as a 
boy, and avoiding girlish games and tastes, she adopts those of boys. 
Later on she becomes mannish, and even amazonian in her manner. 

These homo-sexual perverts practice all kinds of sexual de- 
baucheries. 

Sodomy is a form of sexual perversion Avhich is said to be very 
frequent in most large cities. 

Many individuals who are persistently addicted to masturbation 
are really mild sexual perverts. 

A mild form of sexual perversion is occasionally seen (mostly 
in neuropathic and hysterical women) which is called exhibition- 
ismus. Women addicted to this vice are prone to cause upon 
their breasts, abdomen (chiefly near the genitalia), buttocks, and 
thighs, ulcers induced by severe caustic applications. They deny 
strenuously all self -mutilation, and for a time such cases may be 
looked upon as feigned eruptions. A peculiarity of these patients 
is that they like to submit to physical examination, particularly 
about the breasts and the genitals. Such patients are, as a rule, 
strongly given to erotic thoughts and very commonly are addicted 
to systematic masturbation. A marked instance of this form of 
sexual perversion has been reported by Engmann and Schwab. 1 

1 A Study of a Case of Feigned Eruption. Medical Review, September 2, 1899. 



CHAPTEE XXVIII. 

STERILITY IN THE FEMALE. 

Much marital and domestic unhappiness is often caused by the 
non-occurrence of impregnation of the wife and the resultant 
absence of children in the family. As a rule, in the early years 
of matrimony the want of children on the part of the two consorts 
is not noticed, or, at least, is not keenly felt ; but as years go by 
and no offspring appears, anxiety, discontent, unhappiness, and 
even misery are experienced, and mutual recrimination may be 
indulged in. 

In former years sterility was incontinently laid to the part of 
the wife, but careful observations of late years have quite clearly 
proved that only in five cases out of six is she the consort at fault. 
This fact, that the husband may be the sterile partner in one-sixth 
of all instances, therefore, puts him on trial as well as the wife. 
Therefore, before a married woman shall be suspected of being 
incapable of bearing children the husband and his semen must be 
carefully examined (vide supra) and pronounced virile. 

Sterility is very common in the human race, and is the outcome 
or expression of many and varied morbid conditions. The sexual 
apparatus of woman is very complicated, and anatomical study 
has shown that even in health its mechanism is not thoroughly 
adequate for the harmonious functional activity between the Fal- 
lopian tubes and the ovaries. This point is often well illustrated 
by cases in which the ovum does not fall into the tube, but into 
the peritoneal cavity. 

It is stated on good authority that conception is most likely to 
occur a few days after the cessation of the menses, and that it is 
not liable to occur just before their appearance ; therefore, in seem- 
ingly healthy women who do not become impregnated, it is well to 
ascertain the facts as to the time of coitus. 



STERILITY IN THE FEMALE. 347 

It is said in a general way that high conditions of civilization 
and luxurious and indolent modes of life tend to cause sterility, 
but before we accept this unqualified and unsubstantiated state- 
ment it is well to ascertain whether, for obvious reasons, these 
married people do not shrink from the cares incident to parturi- 
tion and childhood, and whether they do not take measures to 
prevent pregnancy. 

The absence of sexual desire and feeling in some women has 
been urged by some authors as the cause of sterility ; but this 
contention is met with direct evidence which proves that many 
women have borne children who never experienced sexual desire 
and to whom an orgasm was an unknown sensation. 

Though no direct pathological reason can be assigned for it, it 
seems to be established beyond doubt that prolonged intermarriage 
of blood relatives tends in the end to produce at least a relative 
sterility, but it certainly does give rise to rather inferior grades of 
human offspring. 

Sufficient evidence has been offered to prove that obesity, by 
reason of its accumulation of fat in and around the internal sexual 
apparatus of the woman, and its interference with its functional 
activity, is really an important factor in the establishment of ster- 
ility in women. On this subject a very interesting paper has 
recently been published by Dr. J. V. Gaff. 1 

In anaemia, chlorosis, the adynamic conditions following grave 
diseases, and neurasthenia, temporary sterility may occur, which is 
due, in all probability, to the lowered functional activity of the 
ovaries. 

Syphilis in women causes frequent abortions, and in some of 
these cases sterility occurs ; but we are not yet in the necessary 
scientific position to account for these pathological results. 

The sterility so commonly observed in prostitutes is, as a rule, 
due to chronic inflammation of the uterus, of the tubes, and of 
the ovaries. In this connection it is well to remember that 
gonorrhoea is a potent and frequent factor in the production of 

1 Journal of the American Medical Association, January 23, 1897. 



348 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

uterine and pelvic inflammation. Parturition is frequently the 
starting-point of these diseased conditions, which are not infre- 
quently caused by careless and meddlesome surgeons. 

In the case of the absence of the ovaries, of the Fallopian tubes, 
or of the uterus, sterility is always found. 

Chronic oophoritis is a frequent cause of the suppression or 
destruction of the ovule, while in perioophoritis the theca of the 
ovary becomes so thickened that injurious pressure is exerted on the 
secreting portion of the organ. In either event sterility is produced. 

The mechanical adjustment of the ovary to the fimbriated ex- 
tremity of the Fallopian tubes may be impaired or destroyed by 
fibrous bands left by peritonitis, and in this event the ovule can- 
not escape into the uterus, nor can spermatozoa find their way to 
the ovule, consequently fecundation is impossible. 

Ovarian cysts and various neoplasms may so destroy or distort 
the tissues of the ovary that it oan no longer produce ovules. 

Salpingitis is a very frequent cause of sterility. In the catarrhal 
variety, with its hypersemic mucous membrane and the continual 
escape of muco-pus into the uterus, the mechanical conditions are 
such that the irruption of spermatozoa into the uterus and tubes 
is rendered impossible ; therefore impregnation cannot occur. 

In hydrosalpingitis and pyo salpingitis an insurmountable bar- 
rier to the upward migration of spermatozoa is formed by the 
collection of water and pus, and, as in these cases the ovaries are 
usually diseased, it follows that a woman thus afflicted is irreme- 
diably sterile. Chronic interstitial salpingitis results in atrophy 
and stenosis of the tubes, which are then no longer permeable. 

Atresia of the uterus, congenital or acquired, renders impreg- 
nation impossible. 

Atresia of the cervix uteri, caused by overcuretting, caustics, 
syphilitic and chancroidal ulcers, and syphilitic cell-infiltration, 
offers a barrier which spermatozoa cannot overcome. In like 
manner, the plug of dense tenacious mucus which forms in inflam- 
mation of the uterine neck may act as a net which entangles the 
spermatozoa. Ulceration of the cervix with inflammatory hyper- 
plasia of the parts frequently render a woman sterile. 



STERILITY IN THE FEMALE. 349 

In catarrhal endometritis and endocervicitis the mucous mem- 
brane is so altered that the necessary conditions for the fecunda- 
tion of the ovum are absent. In these conditions the profuse 
downward flow of pus both kills and washes away spermatozoa, 
and thus prevents conception. 

Fissures of the uterine neck frequently react so seriously on 
the condition of the uterus that it is rendered unfit for the func- 
tion of conception. 

Hypertrophy of the cervix uteri, together with infiltrative 
hyperplasia, simplex or specific, and elongation and conicity of 
the segment, in which stenosis of the cervical canal is a frequent 
concomitant, is a very common cause of sterility. Malignant and 
simple tumors of the uterus act as efficient barriers to conception. 

In superinvolution, inversion, and prolapse of the uterus such 
abnormal conditions of structure and position exist that impreg- 
nation is rendered impossible. 

In the rudimentary and undeveloped uterus impregnation is 
impossible. 

In anteflexion and retroflexion of the uterus such distortion of 
the lumen of the organ is produced that a barrier to the upward 
invasion of the spermatozoa is formed. 

Anteversion and retroversion of the uterus so throw the organ 
out of position that a purely mechanical impediment is offered to 
the efforts of spermatozoa to reach the interior of the organ. 

Ruptured perineum may cause so much disturbance in the sexual 
parts of women that impregnation is prevented. 

Absence, atresia, prolapse, and cicatricial stenosis of the vagina 
prevent intromission of the penis, and it follows that impregna- 
tion cannot be effected. In some cases in which the vagina is 
very short the semen is lost and fecundation does not occur. The 
same accident is liable to happen to a woman with a very capacious 
vagina, in which all the parts are flabby and relaxed. 

In purulent vaginitis the zoosperms may be killed by the secre- 
tion or carried out of the paths of fecundation by it. 

In small and imperforate hymen such a barrier may exist that 
impregnation is prevented. 



350 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

Uterine fibroids may so distort the organ or cause such dis- 
placement that spermatozoa cannot find a habitat in the cavity. 

It is only intended in this chapter to give a general outline of 
the causes and conditions which produce sterility in women, which 
may form a basis for study and observation. To give full treat- 
ment of the various morbid conditions already mentioned would 
require a very large volume ; therefore, for further details it is 
better for the reader to be referred to the various authoritative 
text-books on gynecology. 



CHAPTER XXIX. 

VAGINISMUS. 

Vaginismus may be defined as an " excessive hyperesthesia of 
the hymen and vulva, attended with such involuntary spasmodic 
contraction of the sphincter vaginae as to prevent coitus." It is 
a somewhat rare affection, and is found in varying degrees of in- 
tensity in women from eighteen to forty years of age and beyond 
that period. 

The mildest cases of vaginismus are seen in young newly mar- 
ried women, particularly those of a nervous or hysterical nature, 
in whom no vulvar or vaginal trouble can be found. In some of 
these cases on attempted intromission of the penis some pain is 
produced, which causes the woman to cry out in agony and the 
sexual parts to become the seat of more or less spasm (sphincter 
vaginae, sphincter ani and levator ani). In some instances, owing 
to the self-abnegation and fortitude of the wife, the painful intro- 
mission of the penis is borne, and then after a few or many trials 
the parts become so dilated that pain ceases and coitus can be 
normally indulged in. In other cases only imperfect coitus is 
effected, on account of the bruising and perhaps laceration of the 
hymen which has taken place at the first attempt. In these cases 
the thought of sexual intercourse throws them into a condition of 
nervous dread and sometimes hysteria. 

It occasionally happens that in women who have had connec- 
tion for years, and even in those who have borne children, a fissure 
or fissures of the vaginal orifice may give rise to well-marked 
vaginismus. In some of these cases the parts are so sensitive 
that the least touch by a finger-tip, a probe, or a feather causes 
involuntary contraction and spasm of the vaginal outlet. 

Cases have been reported in which fissure of the anus has led 



352 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

to well-marked vaginismus, in which coitus was rendered utterly 
impracticable. 

Mild and severe vaginismus is seen in young women in whom 
the free surface of the hymen is thickened in its whole extent, or 
in the form of small or large caruncles. Examination of the 
genital parts in these cases may reveal no abnormality whatever 
in the tissue ; but in some cases the little growths have a whitish- 
pink color, and in others they are decidedly red and inflamed, and 
the contiguous parts of the hymen are in the same condition of 
active hyperplasia. In some of these cases sexual intercourse is 
patiently borne by the woman, and the vaginismus gradually 
ceases ; but in others the act causes agony and terror, and women 
utterly refuse to thus submit themselves. 

There is a form of modified vaginismus somewhat early seen 
in young women who masturbate excessively and who use various 
rigid instruments to titillate the vagina and produce orgasm. As 
a result of these practices the vaginal orifice or the hymeneal 
fringe becomes the seat of hyperplasia in a nodular or annular form, 
and great sensitiveness of the parts, with spasm and sometimes 
pain, is produced. In these cases very frequently hysteria is a 
prominent symptom. 

Inveterate and exaggerated examples of vaginismus are, hap- 
pily, rather rare. They are usually found in married women who 
in the early months of marriage have suffered from bruising or 
painful tears on attempted, but not successful, sexual intercourse, 
which has produced pain and spasm. 

Some of these women still retain their virginity ; others have 
more or less damaged and torn hymen or vulvae ; but in none has 
true intercourse been practised and perfect intromission accom- 
plished. In some of these cases as many as twenty years elapsed 
since the attempted coitus, and in others the period was shorter. 

In these exaggerated cases the whole morale of the patient may 
be destroyed, and they become practically bed-ridden. The late 
Dr. Marion Sims 1 has left a very graphic description of a typi- 

1 Clinical Notes on Uterine Surgery, New York, 1873, pp. 321 et seq. 



VAGINISMUS. 355 

the son of Eleazar, was able to thrust his javelin through the man 
and the Midianitish woman (vide Exodus) ; but the occurrence of 
such cases as the above may offer a possible explanation." 

Treatment. It is gratifying to be able to state that in most 
cases of vaginismus a prompt cure may be produced. In the 
milder class of cases, in which intromission of the penis is im- 
possible by reason of the pain during the attempt at coitus and 
the fear and nervous dread which results from these conditions, 
it is best to follow the procedure employed by Sims — namely, to 
place the woman under an anaesthetic and then allow the husband 
to have intercourse with her. Usually this is the end of the 
trouble of these much worried consorts. Further treatment, how- 
ever, may be necessary, owing to tenderness of the parts and the 
abiding fear of the woman. It is well, then, to use frequent and 
copious vaginal irrigation of hot lead-water and to gradually and 
cautiously dilate the vagina, either with a large- size Ferguson's 
cylindrical speculum or by dilators of varying sizes, made for the 
purpose, of glass. In these manipulations solutions of cocaine 
or eucaine may be used to produce moderate anaesthesia, or sup- 
positories of orthoform may be employed (cocoa-butter and white 
wax with 10 per cent, of orthoform). 

Should any painful spot or tab of hymen be felt which seems 
to cause the vaginismus, it should be fully excised. 

Cases of painful vaginal caruncles should be promptly and ener- 
getically treated by a liberal excision of the parts under strict 
antisepsis. In all these cases it may be well to follow the opera- 
tion by carefully graduated dilatation of the vaginal orifice and 
canal. In some cases the use of absorbent-cotton tampons is 
sufficient. 

The hyperesthesia of the hymen or vaginal orifice caused by 
masturbation may be cured by exsection of the nodules and hyper- 
plastic fringes of the introitus vaginae. 

Too much stress cannot be laid on the importance and the 
necessity for energetic surgical treatment in the cases of invet- 
erate vaginismus. The topography of the vaginal outlet should 
be carefully studied, and then radical exsection should be per- 



356 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

formed. The patient being anaesthetized and the external genitals 
having been made surgically clean, all the free parts of the ostium 
vagina?, hymeneal orifice, fissured hymen, nodular caruncles, and 
mucous membrane tabs should be cut away well down to the 
margin of the orifice. It may also be necessary to make deep 
lateral incisions into the bulbo-cavernous muscles. The parts 
may then be frequently irrigated with plenty of hot bichloride 
solution (1:5000 or 1:2000), and, if necessary, for a time a 
cocaine suppository may be introduced. It is most important 
that systematic gradual dilatation should be kept up until all 
soreness and tenderness of the parts has passed away. For this 
purpose the trivalve, quadrivalve speculum or Ferguson's specu- 
lum, or glass dilators may be employed. 

In cases of what is known as superior vaginismus, in which 
there is spasm of the levator ani muscle and impediment to coitus, 
the woman should be thoroughly and antiseptically douched and 
then placed under ether. Then deep lateral incisions down into 
the muscle into the parts which were found to be the seat of stric- 
ture should be practised. After the operation dilatation by specula 
or antiseptic tampons should be systematically employed. 



CHAPTER XXX. 

MASTURBATION IN THE FEMALE. 

Though it is difficult to get at scientific testimony as to the 
prevalence of masturbation in female children and young women, 
the statement seems to be warranted that this habit is not so fre- 
quent and wide-spread as in the male sex, and that in general no 
great harm is done to the system by the habit. 

Masturbation is sometimes seen in infants and young children, 
both in those who come from healthy parents and in those who 
have a greater or less neuropathic tendency. 

Masturbation in very young infants sometimes occurs, and unless 
the physician is thoroughly skilled in pediatrics the phenomena 
produced by the bad habit may not be understood by the attend- 
ant. For that reason I here transcribe the carefully prepared 
description of a case which is graphically described by an accom- 
plished observer : 

" The first indications of nervous trouble were noticed when 
the child was .fourteen months old. They were very slight and 
occurred when the child was lying in its mother's lap. She sud- 
denly became pale, had a peculiar dazed expression, and her atten- 
tion could not readily be attracted. On being raised up and moved 
she immediately became natural in looks and action. This was 
repeated a few times only, when the attacks changed in character. 
In addition to the appearance of the countenance already described 
there was much muscular rigidity ; the arms became quite stiff 
and strongly resisted being flexed, and the hands were clenched 
and the little fists firmly pressed into the iliac region on either 
side. At the same time the legs were strongly extended at right 
angles to the body, and there was a strong contraction of the 
abdominal muscles, and a straining as if at stool. If the child 



358 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

was held against one's breast she made strong pressure with the 
knees, and up-and-down movements of the body. After a short 
period — a moment or two — the respirations were quickened to a 
rapid panting, and perspiration started freely from the head and 
stood in drops about the mouth. The attacks often terminated in 
sleep. There was at no time any spasmodic or convulsive move- 
ment, or unconsciousness, or mental disturbance beyond an appar- 
ent abstraction. 

" The attacks came on irregularly ; at times with intervals of 
some days, and, again, they were repeated many times a day for 
several days in succession, and sometimes for two or three hours 
with but slight intermission. They never came on during sleep, 
but usually when the child was sitting on the lap, and occasion- 
ally when on the bed or floor. If she was placed on the floor 
early in the attack, and amused with her playthings, it would 
frequently be broken up ; if, however, she was held till it was 
fully developed and then put down she would lie upon her side, 
and the attack would progress as described. " 

It was further noted in these cases that the little girls were apt 
to keep their thighs closely joined, to cross their legs, and to rub 
the limbs violently, sometimes until they became purple in the 
face. 

In some of these young subjects such nervous phenomena as 
epilepsy, Saint Vitus' dance, idiocy, and stupidity have been 
observed. 

Several authors divide the subject of masturbation in women 
as follows : vaginal masturbation and clitoridean masturbation. 
In most cases the vicious practice is performed by the girl or 
woman herself, but exceptionally a male or female confederate 
commits the act on the woman. 

Vaginal masturbation is mostly accomplished by manipulations 
by means of candles and more or less rigid instruments made to 
resemble the penis. This form of vice is usually solitary. 

Clitoridean masturbation is said to be frequently performed by 
a second person, male or female, and consists in friction on the 
surface of the prepuce of the clitoris or upon its glans. 



MASTURBATION IN THE FEMALE. 359 

In some rare cases masturbation is performed by means of 
peculiar manipulations of the face. 

A case is reported of a young woman of twenty-two, of bad 
family antecedents, who had been attacked with psychopathic 
symptoms coincident with menstrual derangement, and for some 
time had been in an asylum. The patient manifested choreic 
movements of the hands, sometimes of one hand, at other times 
of both, terminating by curious manipulations of portions of the 
face. The dorsum of the thumb was placed in the centre of the 
cheek, then with the middle finger pressure was made alternately 
on the tip of the nose and the tragus of the ear. After manipu- 
lating a few times in this way the patient " would fold her hands 
in her lap with a far-away, pleased expression on her face, lasting 
some five minutes." A thorough investigation elicited the fact 
that the patient could produce sexual excitement and satisfaction 
by the manipulations before referred to. She did not seem to 
have any idea of wrong-doing, but was ashamed and surprised 
when the nature of her act was explained to her. This case calls 
attention to a possible explanation of many otherwise baffling 
practices on the part of young children, and should keep the 
practitioner ever on his guard in anomalous cases for possibly 
hitherto unsuspected methods of inducing sexual erethism. 

By consulting many authorities we learn various facts as to the 
causes which lead to masturbation in the female, a general summary 
of which will now be given. In many cases the natural passion- 
ateness of the girl or woman lead to the performance of the act. 

In many cases the too rapid completion of the sexual act in 
the man leaves the woman unsatisfied, and she as a result pro- 
duces the orgasm upon herself at the first opportunity. 

A very common cause of masturbation in girls and women is 
due to lack of care and cleanliness of the genital organs, which 
as a result become irritated and are then scratched or rubbed. In 
this process pleasurable sensations are produced and the onanistic 
habit is formed. 

Eczema, psoriasis, dermatitis, and pruritus of the female geni- 
tals are often the exciting cause of the vice. 



360 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

Many cases are on record in which coitus has been painful to 
women by reason of some structural peculiarity of the external 
genitals, such as small vaginal orifice, shortness of vagina, fissures 
or tabs of the orifice, or of ruptured hymen, perineal fissure, and 
partial prolapse of the uterus, and as a result they have resorted 
to masturbation in place of sexual contact. 

Several authors, particularly Frenchmen, make the statement 
that various spices, cloves, cinnamon, pepper, mustard, etc., may 
lead to masturbation in the female, and that certain odors of per- 
fume, such as musk and patchouli, cause in them erotic desire. 
Cantharides, phosphorus, and absinthe are generally regarded as 
aphrodisiac stimulants. It is generally well known that high 
living and alcoholic beverages act as sexual stimulants to women, 
and may lead to masturbation 

Constipation, by its mechanical congestion of the pelvic organs, 
is said to produce sexual desire and lead to masturbation in chil- 
dren and young women, and pin worms and round worms in the 
rectum very often cause the same train of morbid conditions. 

Vaginal discharges of all kinds cause genital irritation and are 
frequently the starting-point of the onanistic habit. 

As a result of certain exercises in the gymnasium, horseback 
riding, long-continued use of the sewing-machine, and bicycling, 
pelvic congestion and genital irritations are produced which lead 
to masturbation. A sedentary life and long-continued sitting may 
produce the same result. 

The close herding of the sexes and the sleeping together of chil- 
dren and girls with older people are frequently the cause of sexual 
vice and masturbation. 

Many women, young and old, become the victims of onanism 
as a result of the inspection of lewd pictures and nude statues, by 
reading obscene books, and by immoral conversation and gestures. 

The bad example set by one or more girls in a boarding-school, 
in a reformatory, or in an asylum very often leads to an epidemic 
of masturbation in which all the inmates become vitiated. Many 
cases are on record in which female servants and nurses have 
taught masturbation to the young girls under their care. 



MASTURBATION IN THE FEMALE. 361 

Sexual coldness of the husband, personal indifference, impo- 
tence, and senility frequently lead to masturbation in young and 
passionate women. Then, again, widowhood, the long absence or 
perhaps illness of the husband, may cause them to produce orgasms 
upon themselves. French authors have prominently mentioned 
obesity in the woman as being a sufficiently frequent cause of 
masturbation. In these cases, for physical reasons, coitus is ren- 
dered difficult or even impossible, a ad the woman resorts to 
onanism or seeks others to perform the act for her. 

Undoubtedly the condition of the clitoris has much to do with 
the production of masturbation in women. It seems to be pretty 
conclusively proved that shortness of the clitoris may lead to 
imperfect sexual connection by reason of the part not being 
touched and titillated in the sexual act by the penis of the male 
consort, hence no gratification occurs in the woman, and she, 
being then excited and aggravated, has to resort to clitoridean 
manipulation to produce an orgasm. 

In some women the clitoris is highly placed well above the 
upper margin of the vaginal orifice, and in coitus it wholly escapes 
friction from the penis, and as a result there is no orgasm. Such 
women are prone to produce orgasms upon themselves. 

Adhesions of the glans of the clitoris to its prepuce, partial or 
complete, are said to be very common, and when present they 
may cause much disturbance. In the first place, they may be so 
bound down or lifted up that in sexual contact no tit-illation is 
produced by the intromiting penis, and as a result the woman 
has no orgasm. In many cases a woman thus left unsatisfied 
resorts to masturbation. On the other hand, it has been observed 
that the full development of the clitoris has been prevented by 
adhesions, and as a result the function of this sexual appendage 
has been held in abeyance. 

In many cases in which there is no structural defect in the 
clitoris it becomes irritated by the accumulation of smegma, par- 
ticularly in careless and uncleanly women. In such cases the 
urine and vaginal and vulvar discharges produce much irritation 
and erethism and lead to onanistic practices. 



362 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

Several authors state that masturbation in women has been 
superinduced by the aversion and repugnance of men to them, 
owing to their naturally extreme ugliness or to the fact that they 
had been rendered strikingly hideous by physical deformities. 

A very infrequent form of masturbation is termed nympho- 
mania or erotomania, and is observed in degenerate sexual per- 
verts and women with marked cerebral disease. In some women, 
however, in whom there is no insanity, but who labor under 
hysterical and neuropathic tendencies, this habit is sometimes 
observed in a rather milder form. 

These women suffer from inordinate and excessive sexual de- 
sire, and many of them are frequently guilty of great foulness 
and lewdness of speech and action. They unblushingly expose 
their genitals to both men and women, and commit masturbation 
without any attempt at concealment. They are usually women of 
passionate nature and of nervous and excitable tendency. 

Nymphomania is said to follow as a result of prolonged mas- 
turbation and sexual excess, but it is probable that an underlying 
want of nervous balance is the starting-point of these vicious ten- 
dencies and habits. Cases are on record in which well-bred and 
refined women have in the course of nymphomania become so low 
and degenerate that they have used the most obscene language and 
have committed the most libidinous actions. 

It is said that uterine and ovarian diseases tend to produce 
nymphomania, also called furor uterinus, in some cases ; but in 
all these instances it is most important to look carefully and fully 
into the condition of the nervous system. 

In some of the milder cases of nymphomania women develop 
a remarkable tendency to undergo operations upon and examina- 
tion of the sexual organs. 

Several cases have been reported in which women suffering 
from marked sexual erethism have pretended to suffer from re- 
tention of urine, and have been much comforted by the with- 
drawal of that fluid by means of the catheter of the surgeon. 

As a result of extended recent studies in nervous and mental 
diseases the conviction seems to be growing that excessive mastur- 



MASTURBATION IN THE FEMALE. 363 

bation is a symptom of nervous debility and disease rather than 
the exciting cause of these morbid phenomena. 

In the older books much stress was laid upon the facies of the 
girl or woman addicted to masturbation. As far as I can learn, 
in most cases masturbation in women (which it is probable is not 
very frequent) is indulged in in moderation, and no untoward 
effects are produced ; certainly none which will appear at all 
pathognomonic. Neither in their appearance nor in their actions 
do these women present any unusual condition. 

In some cases in which females indulge excessively in mastur- 
bation, a deterioration in the health of the patient may be observed, 
but these women promptly get well under proper hygienic care 
and on ceasing to indulge in the bad habit. 

Excessive masturbation in women is said to show itself in 
pale, sallow, and expressionless face, sunken eyes surrounded 
by blanched circles, and a secretive and hang-dog looking facies. 
Such women have cold, clammy hands, a generally poor circula- 
tion, small, rapid pulse, and a tendency to shortness of the breath. 
Indigestion, constipation, and insomnia are frequent and concom- 
itant symptoms. It will be seen that there is nothing absolutely 
characteristic in any of these symptoms, all of which are fre- 
quently found in neurasthenics and hysterical women. 

The local effects of masturbation in women can be seen in 
enlargement of the prepuce of the clitoris and of this organ itself, 
a pigmented condition and excessive development of the labia 
minora, and perhaps hyperplasia and hyperesthesia of the orifice 
of the vulva. 

Treatment. In the management of young girls who are 
addicted to masturbation the most careful surveillance and watch- 
fulness on the part of the mother are necessary. When the symp- 
toms point to manipulation of the genitals the child should be 
stopped at once, and she should be held in the lap with the 
thighs extended. Any condition of ill -health should be carefully 
treated, and if any irritation of the external genitals is observed 
it should be cured. When young girls are herded together at 
home or in boarding-schools, asylums, etc., it is important to 



364 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

t 

watch them carefully and prevent, if possible, the indulgence in 

bad sexual habits. 

It is always well for mothers of young girls and boys to scru- 
tinize carefully the habits and conduct of servants and nurses, 
and to see that they do not teach the children bad habits and 
that they do not manipulate their genitals. 

In all cases irritation of any and all kinds of the sexual parts 
of children should receive prompt attention and be thoroughly 
removed. When it comes within the province of the surgeon 
in the various cases he should endeavor to prevent onanistic 
habits, which young women acquire in gymnastic exercises, 
horseback riding, in the use of the sewing-machine and of the 
bicycle. 

In all cases the general hygiene and regimen of the patient 
must be looked into, and sound advice must be given. 

The condition of the clitoris must be carefully examined in all 
cases of confirmed masturbation. If there is smegma seated on 
the organ and under its prepuce the parts should be regularly 
and carefully cleansed, and for a time a little tuft of absorbent 
cotton soaked with lead-water should be kept over the parts. 

Irritation of the clitoris from any cause, such as uncleanliness, 
pediculosis, dermatitis, vulvitis, and vaginal discharges, should 
be at once treated and the cause removed. 

In all cases where adhesions of the prepuce to the clitoris, 
whether partial or complete, are present it is imperative to cor- 
rect this defect at once. To this end it is first necessary to thor- 
oughly irrigate the vagina and vulva with hot bichloride solution 
(1: 5000 or 1: 2000), then to cocainize the parts, and then by 
gentle taxis or by manipulation with a probe or the handle of a 
small bistoury to slowly disengage the enveloping tissues from 
the glans. 

This operation is very simple, and the subsequent treatment 
consists in the interposition of a little tuft of absorbent cotton 
covered with aristol or orthoform or soaked in lead-water. It 
is well to keep the interposed cotton in the wound until full 
healing is produced. 



MASTURBATION IN THE FEMALE. 365 

Cases of nymphomania are very distressing, and they tax the 
surgeon severely in its treatment. Locally in some of these cases 
full exsection of the clitoris (clitoridectomy) may be performed, 
but in these cases the surgeon should seek consultation with one 
or two expert colleagues. The nervous condition of these patients 
should be fully and carefully treated. 



CHAPTER XXXI. 

NEW GROWTHS AND HYPERTROPHIES OF THE VULVA 
WHICH MAY LEAD TO STERILITY. 

It is noticeable that in the various text-books on diseases of 
women little if any information on broad ground is given con- 
cerning hypertrophic lesions and simple new growths of the 
vulva. In a number of scattered essays these important subjects 
have been considered, but no definite and systematic description 
of them has been given. A fair presentment of the discordant 
views held to-day regarding simple (and by that I mean all pro- 
cesses not included under the head of malignant degeneration) 
hypertrophic and ulcerative vulvar lesions is as follows : 

1. That they are identical with lupus or the esthiomene of 
Huguier and French authors generally. 2. That they are the 
result of essential and specific syphilitic processes. 3. That they 
are the result of some indeterminate ulcerative process. 4. That 
certain cases may be the result of tuberculous infection. 

It may be further added that certain of those who do not 
accept the lupus theory look upon these affections as being pecu- 
liar and even extraordinary, and while some even regard them 
as mysterious and specific, they only indulge in generalities in 
speaking of them. 

This being the condition of the uncertainty of opinion and of 
the inadequacy of systematic description, I availed myself, during 
a period of many years' service at the Charity Hospital, of the 
opportunity to study these lesions on many thousand cases of 
women with sexual and genital disorders. As a result of these 
observations, supplemented by microscopical study, I have reached 
the following conclusions : 

1. That a large and perhaps the greater number of chronic 
deforming vulvar affections are due to simple hyperplasia of the 



NEW GROWTHS AND HYPERTROPHIES OF VULVA. 367 

tissues, induced by irritating causes, inflammation, and trauma- 
tisms. 2. That chronic chancroid is a cause in a certain propor- 
tion of cases. 3. That many eases are due to essential and spe- 
cific syphilitic infiltrations. 4. That other cases are caused by 
the hard oedema which often complicates and surrounds the initial 
sclerosis and perhaps gummatous infiltration. 5. That many cases 
are due to simple hyperplasia in old syphilitic subjects who suffer 
from chronic ulcerations of the vulva long after all specific lesions 
have departed. 6. That some cases also in old syphilitics are due 
to simple hyperplasia without the existence of any concomitant 
ulcerative or infiltrative process, and seem to be caused by con- 
ditions which usually in healthy persons only result in vulvar 
inflammation. 

In the foregoing categories the acting, contributory, and remote 
causes are briefly outlined. 

The systematic division of these new growths and hypertro- 
phies is very essential in order that a clear and comprehensive 
knowledge of them may be gained. My studies have convinced 
me that this subject can most lucidly be treated of by the recital 
of the facts presented by the smaller orders of lesions, which form 
an excellent groundwork for a clear knowledge of the larger ones. 
Clinical observation shows that these lesions are divisible in the 
following categories : 

1. Small hyperplasia?, caruncles, and papillary growths. 2. 
Large hyperplasia? and hypertrophies. 3. Hyperplasia resulting 
from acute and chronic chancroids. 4. The various forms of 
hypertrophy induced by the induratiug oedema of syphilis. 5. 
Hyperplasia resulting from chronic ulcers, the so-called chan- 
croids, in intermediary and old syphilis. 6. Hyperplasia in old 
syphilitics, presenting no specific character and occurring soon 
or long after the period of gummy infiltration, in some cases 
being coexistent with specific lesions elsewhere. 

The foregoing affections have neither in their clinical history 
nor their pathology any resemblances to lupus, nor do they par- 
take in any manner of the nature of lesions produced by tuber- 
cular infection. 



368 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

In the last periods of many cases iu which ulceration and 
destruction are very great, evidences of pulmonary phthisis may 
be seen, but my observation convinces me that the tuberculous 
infection does not occur through the genitals, but in the lungs of 
women worn and spent with disease. Many authors, particularly 
French, have laid stress on the point that these vulvar lesions are 
the outcome of scrofula. 

In the following chapters these vulvar affections will be suc- 
cinctly described. 

In many of these cases the walls of the vagina are also involved 
to a greater or less extent and depth. 



CHAPTER XXXII. 

VEGETATIONS OF THE VULVA. 

Ix general vegetations of the vulva may be classed among the 
smaller growths, though they may become very large. These 
smaller orders of tumors are, first, papillary growths or vegeta- 

Fig. 76. 




Small vegetations in a young female child. 

tions, commonly called warts, and, second, hyperplasias of the 
various prominences, folds, and anfractuosities found within the 
more or less complete ellipse formed by the labia minora. 

24 



370 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

Vegetations of the vulva may occur singly or in various num- 
bers, and are prone to develop in the vulvar sulcus, chiefly around 
the urethral and vaginal orifices, in children, and more frequently 
in adults, at or beyond puberty. They are commonly seen on all 
portions of the vulvo-anal region, and show no tendency what- 
ever to localization to the vulvar ellipse. They are of a pinkish 
or deep-red color, spear-shaped, digitate, sessile, pedunculated, 
cauliflower-like, or they may resemble strawberries of various sizes. 
They are essentially papillary hypertrophies, and show a tendency 
to exuberant growth. The latter feature and their tendency to 
irregular and scattered development are points of diagnostic value 
in separating them from hyperplastic lesions considered further on. 

Fig. 77. 




Exuberant vegetations of adult female genitals. 

These vegetations begin as very minute red spots of erosion, 
which soon become elevated, and, if many are present, the mucous 
membrane at first presents a velvety appearance. In a short time 
these little masses become true warts with more or less papillated 
external structure. Their appearance in early development is well 
shown in Fig. 76. They rapidly grow larger, and coincidently 
very many new ones appear, until (if treatment or preventive 
means are not adopted) the whole vulva and the surrounding 
regions may be literally covered. The appearance of exuberant 
vegetations on the female genitalia are portrayed in Fig. 77. 



VEGETATIONS OF THE VULVA. 



371 



Vulvar Hypertrophy Consequent upon Vegetations. 

There is a form of hypertrophy of the vulvo-anal region of 
women which I believe has not heretofore been mentioned by 

Fig. 78. 




Showing simple vegetations in process of change into fleshy tabs and 
hypertrophic masses. 

authors. The initial stage of this form consists in the develop- 
ment of simple vegetations on any part of the external genitals. 



372 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

Owing to neglect, want of care and cleanliness, and of surgical 
intervention, these growths become enlarged, as they also usually 
increase in numbers. As they grow in height and breadth, par- 
ticularly those on the outer portions of the labia majora (where 
they are subject to continuous friction), they lose their warty 
appearance and come to look like nodules, processes, or tabs of 
skin. They are, as it were, polished off, losing entirely their 
granular, strawberry -like look, and taking on the appearance of 
integument. In Fig. 78 this form of hypertrophy, in its initial 
and advanced stages, is well shown. The figure was taken from 
life, from a young pregnant woman who had suffered for a long 
time from leucorrhoea, the irritation of which led to the develop- 
ment of the new growths. In the depth of the vulva three rows 
of typical vegetations may be seen, and on the outer edge of each 
of the labia majora a string of fleshy masses, which had been 
vegetations, but which had undergone the polishing-off process, 
may be seen. Over the perineum are a number of conical tumors 
of like origin, and hanging over the anus are a large gourd-shaped 
mass and several smaller ones, which had resulted from the trans- 
formation of several clusters of very exuberant warts. Unless 
ablated, these tumors inevitably lead to great hypertrophy and 
disfigurement of the parts. They, acting as low-grade inflamma- 
tory foci, induce hyperemia and hyperplasia in the vulva, and in 
the end lead to its great distortion. I have many times seen this 
general hypertrophy of the external genitals by warts, and I recall 
an instance in which these growths, being very large, were ablated, 
and in their stumps hyperplasia took place, which led to great 
deformity. The practical teaching of these cases is not only that 
these new growths should be thoroughly removed, but that great 
care should be taken that their sites shall not become the foci of 
hyperplastic new formations. 

Hyperplastic Growths of the Vulva. 

Simple new growths of the vulva have been variously called 
polypi of the urethra and of the vagina, hypertrophied caruncles 



VEGETATIONS OF THE VULVA. 373 

— berry-like tumors — villous growths, warty excrescences, and 
papillary polypoid angeionia. Though there is much uncertainty 
in the minds of medical men as to their real pathology, and though 
the most varied views are entertained as to their essential nature, 
the matter is a very simple one. In my studies of the larger 
orders of hypertrophies I included a consideration of the path- 
ology and clinical history of these smaller ones. As a result I 
found that, clinically, the larger growths were but exaggerations 
of the smaller ones, and I also learned, through pathological and 
microscopical studies, that the morbid process observed in small 
lesions can be traced in progressive and undeviating development 
through all sizes of these simple hypertrophies until the enor- 
mously large ones are reached. I thus strongly state these facts 
for the reason that I have seen the affection begin in an insignifi- 
cant manner on or within the labia minora, and in the course of 
years eventuate in the development of enormous vulvar hyper- 
trophy. Further than this, I have been able to confirm the clin- 
ical facts which I have observed by what I deem satisfactory and 
convincing microscopical studies of the small, intermediate, and 
large lesions which I excised. 

The small growths of the vulva, which may properly be called 
hypertrophied caruncles and simple hyperplastic tumors, are found 
either singly or in numbers of from two to a dozen or more. 
They are sometimes very small, of the size of a large shot, or as 
large as a pea or a strawberry, or even larger. They may pre- 
sent a decided firmness of structure, or they may be soft and 
vascular, and between these two extremes there are many grada- 
tions. They may be of a pale-pink color, of a bright scarlet-red 
tint, of a deep-red, or of a purplish hue. When they are very firm, 
the hyperplasia is composed of all the cell elements of the mucous 
membrane and fibrous tissue, and the new growth of vessels is 
not excessive ; but in the softer variety there is a greater amount 
of new-vessel development, consequently they are more vascular, 
of deeper color, and softer in structure. These facts will fully 
explain the varying clinical features of density and color. I may, 
in passing, remark that these lesions may give rise to no uneasi- 



374 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

ness whatever, but may also be the cause of great suffering, par- 
oxysmal or continued. 



Urethral Caruncles. 

On the lips of the meatus urinarius and within the urethra, 
more frequently on its posterior wall, one or more small or large 
warts are sometimes seen, and they are then called urethral 
caruncles. It is not uncommon for these lesions, even when 
very small, to become extremely sensitive, and even the seat of 
great pain, particularly in urination. This pain may radiate to 
the parts around, and even down the legs. Not uncommonly 
bleeding may occur from a caruncle, and during micturition there 
may be severe spasm of the vesical sphincter. Cases have been 
observed in which one little urethral caruncle has produced such 
pain, distress, and anxiety that patients have fallen into severe ill- 
health and have suffered intolerable agony. Warts seated near 
and around the introitus vaginae are also in some cases the seat of 
pain, and they may prevent coitus. 

When vegetations are few in number they may remain isolated, 
and as they grow they attain the size of strawberries, and they 
may resemble them in appearance or become of a dark-purple 
color. In these instances they are sometimes regarded as cancer- 
ous, and in times past they have been diagnosticated as lupus- 
growths. In young women these lesions are, as a rule, simple in 
nature. As age advances one must be more guarded in prognosis, 
since in old persons simple warts have a tendency to cancerous 
degeneration, and epithelioma of the vulva very often begins in 
a lesion which resembles a simple wart. As a broad, general rule, 
warty lesions of the vulva before the fortieth or fiftieth year are 
of simple nature ; after these periods their structure is often doubt- 
ful, and the surgeon should strongly suspect epithelioma, and at 
once have a microscopical diagnosis established. 

It must not be assumed that all small growths increase in size 
and eventuate into larger ones. Many remain for years without 



VEGETATIONS OF THE VULVA. 375 

any increase in size, others become larger and troublesome, and 
are excised, and perhaps but few reach large proportions. Social 
position, personal cleanliness, and many other considerations tend 
to determine the life-history of these growths. It should always 
be remembered that, as age increases, these benign growths are 
very liable to become malignant in character. This is particu- 
larly the case with the more vascular ones. Consequently, the 
surgeon should always recommend their ablation in women about 
and beyond forty years of age. 

Treatment. The indications for the treatment of vegetations 
are their complete removal and the prevention of their return. In 
every instance the immediate and surrounding parts should be 
thoroughly washed or irrigated with solutions of carbolic acid 
(1:100) or of the bichloride of mercury (1:2000); then the 
surfaces and interstices of the warts should be thoroughly painted 
with an 8 per cent, solution of muriate of cocaine. In very 
nervous women in whom the lesions cover a large or delicate sur- 
face, mild chloroform narcosis or ether-narcosis may be required. 
This condition being induced, the necessary treatment can be 
more thoroughly and easily instituted. 

It may be stated as an axiom that surgical procedures for the 
removal of vegetations are much more rapid and effectual than 
caustics are. The latter, however, are useful under certain cir- 
cumstances. When the vegetations are small they are readily 
removed by the dermal curette or Volkmann ? s spoon, the scraping 
being carried well to the level of the tissues, which, however, must 
not be wounded. A solution of persulphate or perchloride of 
iron should be carefully touched to the bleeding points, and the 
parts, when dry, quite firmly covered either with iodoform gauze 
or absorbent gauze — never with watery solutions. Such is the 
tendency to recurrence of these growths that the cure cannot be 
considered complete until the surfaces are smooth. In cases of 
recurrence, before the little growths have reached much salience, 
chloroacetic acid, lactic acid, acid nitrate of mercury, nitric acid, 
the various solutions of iron just spoken of, and strong tincture 
of iodine may be employed. Bichloride of mercury (thirty grains 



376 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

to the ounce of collodion) or salicylic acid (one drachm to the 
ounce of collodion) is sometimes a very effectual solution for 
small warts and those for which curetting is contraindicated. 

Sessile or pedunculated warts of an area of an inch or more 
may be readily removed by strangulation with a silk ligature. 
In some cases this object may be accomplished by the elastic liga- 
ture, using the ordinary small India-rubber bands, fixed firmly 
around the base of the warts ; still, in all cases in which it is 
practicable, scraping is the best treatment. 

Warts of larger area than an inch are best treated by the gal- 
vano-cautery loop, and these cases are the only ones in which this 
method of removal is really indicated. Their ablation must be 
slowly and carefully effected with the least loss of blood. Their 
further treatment is similar to that of the small growths. Rigid 
antisepsis is required in every case. 

The utmost care must be observed in removing vegetations 
about the meatus, and when possible scraping or tying should be 
employed. The parts should be viewed in a clear light, and a 
urethral speculum should be used in order that no new growth 
may escape. When curetting is impracticable salicylic or bichlo- 
ride collodion or tincture of iodine may be used very carefully. 
The idea is simply to remove the new growth and avoid damaging 
the parts and causing stricture of the urethra. As a rule, acids 
are contraindicated in this region. 

In cases where operative procedures are not admissible, whether 
owing to the size or situation of the warts it is well to apply freely 
to them, after preliminary fomentations with very hot water, fol- 
lowed by washing with bichloride or carbolic solutions, equal parts 
of calomel and salicylic acid. 

There is a popular fallacy that warts in pregnant women should 
not be removed for fear of producing abortion. This view was 
the outcome of the old and now, happily, nearly obsolete treat- 
ment by vigorous and intemperate cauterization, which produced 
great vulvar and vaginal inflammation, and sometimes rigidity, 
even stenosis, of the genital tract. No such results are produced 
when the growths are removed by curetting or other surgical 



VEGETATIONS OF THE VULVA. 377 

means supplemented by rigorous antisepsis. Since vegetations 
may act as impediments to parturition by reason of their own 
size and position and of the oedematous hyperplasia which they 
cause, they should always be promptly and thoroughly removed. 

After removal the surgeon should explain to the patient the 
conditions under which warts grow and luxuriate, with a view to 
prevent their recurrence. 

In persons beyond forty years of age persistent recurrence of 
an originally simple wart should always awaken suspicion of 
malignancy, and prompt and radical extirpation should be prac- 
tised. 



CHAPTER XXXIII. 

LARGE HYPERTROPHIES OF THE VULVA. 

The larger orders of vulvar hypertrophies, like the smaller 
ones, may be found in early puberty, up to middle life, and are 
less common in persons beyond fifty years of age. 

These hyperplasias are, as a rule, the direct result of some irri- 
tation or of traumatism. Vulvar inflammation, whether simple 
or the outcome of antecedent chancroids, vaginitis, herpes pro- 
genitalis, leucorrhoea, gonorrhoea, uncleanliness, masturbation, 
tears in coitus and parturition, scratches, cuts, bruises, eczema, 
and all forms of traumatisms have been found to be exciting 
causes. 

It is impossible to give a systematic and comprehensive descrip- 
tion of these hypertrophies, since they all differ from one another. 
This is due to the fact of the very great variation in the confor- 
mation of the vulva in women. In some the labia majora are 
large, in others very small and exceptionally absent. The labia 
minora are seen in an infinite number of sizes, shapes, and gen- 
eral configurations. Some are long and thin, some short and thick, 
some smooth on their free edge, others irregular and perhaps fes- 
tooned and frilled. Then the structure of the vestibule, the con- 
dition of the introitus vaginae, and the shape of the fourchette are 
found to vary so greatly that nothing like uniformity occurs. It 
can be readily seen, therefore, that a good-sized essay could be 
written on all the varying appearances offered by these vulvar 
growths, and then the limit would not be reached. 

In some cases there is simple enlargement of the natural parts, 
but in the majority there is more or less deformity, and even dis- 
tortion. Very little of diagnostic importance is offered by a study 
of the various shapes and sizes of these growths. A clear idea 



PLATE XL 




Hypertrophy of the Right Nympha and Perineum. 



LARGE HYPERTROPHIES OF THE VULVA. 379 

of the appearance and history of them can best be given by the 
pictures and details of three cases. The first case (see Plate XI.) 
shows the localization of the affection in one nympha, and its his- 
tory is as follows : 

A woman, aged twenty-eight years, free from syphilis, had 
severe attacks of herpes progenitalis involving the right labium 
minus. About six months later she had a profuse purulent vagi- 
nal discharge for a time, and then noticed that the right labium 
minus was sore and slightly inflamed. In a short time the in- 
flamed part became noticeably enlarged and of a deep pinkish-red 
color, until it reached the proportions shoAvn in Plate XI. It is 
seen to be a flat tumor, semicircular in shape, quite deeply in- 
dented on its free margin and limited sharply to the right labium. 
Its color was of a whitish-pink when the patient was long in the 
recumbent position, and of a pronounced pinkish hue when she 
walked very much. She was very clear as to the fact that in its 
early days the tumor was of a rosy-red color, softer and thicker 
than now, and that as it had grown older it had become decidedly 
contracted and much firmer in consistence. At the base of the 
enlarged nympha corresponding to the introitus vaginae were two 
small superficial ulcers of simple character. The perineal rhaphe 
were somewhat thickened and ended in a thickened and flabby 
pouch-like mass of skin, which hung over the unaffected anus as 
she lay on her back. The inguinal ganglia were unaffected. Be- 
yond a sensation of heat and pruritus, which occurred in short 
paroxysms, the patient experienced no discomfort. 

It will be noted that the labial hyperplasia began in this woman 
at the age of twenty-eight, and reached the size depicted in Plate 
XI. in about two years. 

It is important here to call attention to the flabby, pouch-like 
tumor at the anal orifice, since growths like it are so common in 
all cases of vulvar hypertrophy, whatever may be their origin. 
These protrusions are not, strictly speaking, piles, for the reason 
that they are not of necessity connected with the anus, certainly 
in their early stages. They seem to begin as hyperplasias of the 
skin of the perineum, and as they grow to settle themselves on 



380 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

the anterior margin of the anus. In the uncomplicated condition 
they do not impinge upon the anal orifice, but as they grow larger 
and broader they involve that outlet more or less, at first on its 
in tegumental part, and later, in very chronic cases, the rectal 
mucous membrane may become affected by the hyperplasia. 
The second case shows still further vulvar involvement : 
A woman, aged twenty -five years, American, single, had cohab- 
ited with men from her sixteenth year, but was free from syphilis. 
She had had numerous attacks of mild vulvar and vaginal inflam- 
mation, due to sexual irritation, but gave no history of gonorrhoea. 
About a year before the date of operation she noticed that the 
caruncula? myrtiformes were rather red and tender, and that some 
of them soon increased to the size of small peas, being firm and 
somewhat shotty to the touch. Then she noticed that her exter- 
nal genitals were growing larger and protruded, whereas in former 
years the nymphae had habitually been closed in by the labia 
majora. In the early period of development of these vulvar 
growths they were of a bright-red color, and from their inner 
surfaces bloody serum exuded at times. On one occasion a mild 
hemorrhage took place, which lasted several hours. At this time 
also the thickness of the labia was much greater than it was 
when the swellings became as large as shown in the figure. She 
experienced very little occasional heat and pruritus in the parts, 
and only applied for relief when they became rather obstructive 
to copulation. When first seen the nymphse and clitoris were 
much hypertrophied. The left tumor was fully five inches long, 
and by traumatism became gangrenous in its distal half, which 
soon fell off. The parts presented the appearance and color of 
integument, were firm, even leathery and resistant, not at all sen- 
sitive, perhaps rather callous, and they had an irregular lobulated 
and nodulated contour. They are well shown in Fig. 79. On 
several occasions mild and ephemeral ulcerations had existed in 
the deep vulva, but they caused no uneasiness. Two weeks after 
removal of the hypertrophied parts the woman stated that she was 
as well as ever, and left the hospital. In this case the irritation 
from the myrtiform caruncles extended to the lesser labia, and 



LARGE HYPERTROPHIES OF THE VULVA. 



381 



this led to their hypertrophy. In the early stage of the affection 
the parts were softer, more succulent, and redder ; as it grew old 
they became condensed and gradually lost their color, until they 



Ficx. 79. 




Showing hypertrophy of both nyniphse and of the sheath of the clitoris. 



382 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

came to closely resemble ordinary integument. The general 
health was wholly unaffected. There was no involvement of 
the inguinal ganglia. 

In this case, as a result of simple local inflammations, the myr- 
tiform caruncles became inflamed, and then hyperplastic, and from 
these foci the new growth extended and involved the labia minora, 
including the prepuce of the clitoris, and that organ itself, in hyper- 
trophy. The low form of inflammatory, red, oedematous infiltration 
of the vulva which was observed early in the woman's medical his- 
tory will be fully discussed later on. In this and the preceding 
case the limitation of the morbid process to the vulva and nymphse 
is clearly marked. In them, also, the tendency of the affection 
to push outward and downward is well shown. Later on, how- 
ever, the deeper parts very often become invaded. This case, 
therefore, may be accepted as a typical one, showing the involve- 
ment of each and all of the parts of the vulva. Though the 
introitus vagina? was at the date of the operation thickened and 
less supple than normal, this conditiou was undoubtedly due to 
symptomatic irritation, since in a few weeks after the operation 
the natural condition of the parts was restored. 

In Plate XII. we observe the acme of the hyperplastic process 
of vulvar distortion, which centred itself in the prssputium clitor- 
idis and a part of a nympha. 

A woman, aged twenty-six, Irish, married, had not suffered 
from any vulvar or vaginal affection. Six months before the 
operation she had fallen upon a fence and wounded the mons 
veneris and upper part of the vulva. These regions were the 
seat of ecchymosis and pain for about two weeks. Shortly after 
the patient noticed a protrusion from the upper part of the vulva, 
but, as it was unaccompanied by pain or inconvenience, she paid 
no attention to it. It, however, grew quite rapidly, until in about 
eighteen months the growth measured four inches, and, besides 
being very inconvenient from its bulk and situation, it caused 
uneasiness by its weight. The patient noticed that when she 
was on her feet very much the tumor was larger and of a deeper 
color than it was if she remained recumbent. There was no 



PLATE XII. 




Enormous Hypertrophy of the Clitoris, with 
Part of the Left Nympha. 



LARGE HYPERTROPHIES OF THE VULVA. 383 

affection of the inguinal ganglia. The mass is well shown in 
Plate XII. It was rather more than four inches long and about 
two inches at its widest part. It involved the prepuce of the 
clitoris and a portion of the upper part of the left nympha. It 
was hard and firm in consistence, of a pinkish-white color, and 
its surface was studded with lobulations and intersected with large 
and small furrows. It was ablated and the woman left the hos- 
pital cured. 

A special point of interest in this case is the rapidity of devel- 
opment of this enormous growth. Assuming that the patient's 
story was correct (and great care was taken to get at the truth), 
the large mass was developed in about eighteen months. This 
I may say is .very exceptional, for in several other cases I have 
noted that the time occupied in the growth of hypertrophy of the 
clitoris has been two or more years. In the present instance the 
trouble began in trauma, but I have seen a number of cases in 
which hypertrophy of the prepuce of the clitoris was due to mas- 
turbation. I have now under observation a woman of twenty-two, 
who, since her twelfth year, has produced almost daily one or two 
orgasms by digital irritation of the clitoris, and yet the hypertro- 
phied mass is not larger than the first joint of one's thumb. 

In this affection it is very probable that the hyperplastic pro- 
cess begins in the prepuce, and that later on the body of the 
clitoris is involved. 

These hypertrophic growths of the vulva have been wrongly 
called elephantiasis, notably by Hildebrandt, and more recently 
(1885) by Zweifel. Neither in their clinical history nor in their 
pathological anatomy do they in any way resemble true elephan- 
tiasic growths, which are due to lymphatic inflammation with con- 
nective tissue increase. They are elephantine only in size. 

There are a number of conditions relating to the early stages of 
these vulvar hyperplasia? which demand consideration. In many 
subjects, particularly young, cleanly, and healthy ones, these 
hypertrophic growths run their course to full development with- 
out any perceptible signs of inflammation. The growths in these 
subjects are, while increasing, of a pink or pinkish-red hue, and, 



384 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

as they grow larger and push from between the labia majora, they 
become blanched, and finally may look like integument. 

In another class of cases, particularly in unhealthy, uncleanly 
women, in those subject to any vaginal discharge, and in women 
about and after the menopause, we see synchronously with their 
growth a decided increase in their inflammatory and oedematous 
features. In these cases there is always more or less concomitant 
vulvar hyperemia. The hyperplastic parts (when their mucous 
membrane is yet intact) are either of a deep-red or of a dull-violet- 
red color. They have not the firmness of structure, perceptible 
to the touch, of the less hypersemic growths, but are rather softer 
and, we may say, more succulent — a condition, in all probability, 
due to a correlated oedematous exudation. 

In this soft and succulent stage of the hypertrophies there is, 
besides the lesser degree of sharp limitation and of localization, a 
decided tendency to ulceration, particularly in the fissures, sinu- 
osities, and anfractuosities which are found in them. In all 
uncomplicated cases of these simple forms of hyperplasia it will 
be evident to a careful examination that the ulcerative process is 
always secondary to the hypertrophy. It is usually plain to the 
observer that the power of resistance of the morbid tissues to 
irritation is greatly impaired, and that when pressure exists, as 
from close coaptation of the parts, or when any irritation is ex- 
erted, there will be found ulceration. These ulcers, however, do 
not present any pathognomonic features, and it is amusing to 
peruse the descriptions of these lesions by those who lean to the 
view that they are due to lupus. The writers see distinctly 
that the ulcers have not a lupoid look, and they go over point 
after point trying to reconcile in their minds the evident discrep- 
ancies. 

We find as concomitant features of these vulvar hypertrophies 
simple excoriations, smooth ulcerations, with or without slight or 
pronounced granulating tendency, indolent conditions, and some- 
times sluggish ulcers covered with necrotic detritus. They are 
almost always, however, in uncomplicated cases, what we may 
term simple ulcers, having the most varied shapes —linear, penni- 



LARGE HYPERTROPHIES OF THE VULVA. 385 

form, irregular, and stellate — and differ very markedly from those 
we shall study in the two following chapters. 

But simple as they are, they exert a very bad effect upon the 
course of the new growths. They tend to increase the morbid pro- 
cess itself, and they themselves very often grow and cause incal- 
culable mischief. Thus they may burrow and cause fistulous tracts 
into the labia and urethra, work their way forward and cause 
vesico-vaginal fistula, pass backward into the ischiorectal space, 
and even into the rectum, forming a channel between it and the 
vulva or vagina. Then, again, they frequently lead to necrosis of 
small and even large hypertrophic growths by eating them away 
at their bases. 

These ulcerations often cause mild and even severe hemorrhage, 
which is usually readily controlled when they are superficial, but 
which may be very intractable when they are deeply seated. 

It not uncommonly happens, when both sides of the vulva, as 
is very common, are the seat of hypertrophy in the succulent 
stage, that excoriation of the coapted surfaces occurs, and from 
them there is an oozing of bloody serum or blood. It is this 
condition, undoubtedly, which the older writers observed in what 
they called oozing tumors, and which later on has been labelled 
hemorrhagic lupus. 

In favorable cases the succulent stage of these growths gradu- 
ally subsides and the parts slowly pass into the condition of 
condensation, until in the end a dense, leathery state may be 
reached. 

In bad cases — and they are generally in old women — however, 
the trouble extends, and destruction of the vulva and its canals is 
more or less complete. In this event the patient gradually wastes 
away from marasmus, dies of phthisis, or of chronic diarrhoea or 
dysentery. For many years, however, the general health may 
remain unchanged, and only when the destruction is great, and 
the natural outlets of the body more or less destroyed, do signs 
of breaking up begin to show themselves. 

When ulceration attacks these hypertrophies there is very often 
more or less enlargemeut of the inguinal ganglia. 

25 



386 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

I have been particularly struck with the fact that I have never 
seen cancerous degeneration of any of these hyperplastic growths, 
even when they have become very old and when very much irri- 
tated. The little red vascular tumors of the caruncles and vulvar 
fringes may from irritation become epitheliomatous in women 
toward and beyond forty years of age, but when they have 
reached the stage of condensation they, like their larger con- 
geners, may become much inflamed and ulcerated, may be the 
seat of abscesses, aud may slough off, but they show no tendency 
to become epitheliomatous. This is probably due to the fact that, 
with the thickening of the skin, it becomes impervious to the 
invasion of exuberant epithelial tissue from without. 

In some cases I have seen much ephemeral hyperemia and an 
erysipelatous condition of the growths and parts around them, 
particularly in those who had become infected with gonorrhoea, 
who had vaginal discharges and were uncleanly, and also in women 
who had returned to the hospital after a protracted debauch. 

In their succulent stage these hyperplasia? might possibly be 
mistaken for epithelioma, but the mistake should not last long. 
Epithelioma is usually more localized, of a much greater density 
even to stoniness, is productive of a large warty or papillomatous 
and ulcerated surface, and is very soon accompanied by enlarge- 
ment of the inguinal lymphatic ganglia. The ulcerations of epi- 
thelioma are upon the surface of the neoplasm, while those of 
simple hyperplasia are mostly found in the interstices and fissures 
and at the bases of the simple hypertrophies. Epithelioma of the 
vulva gives rise to pain of a lancinating character, while the sub- 
jective symptoms of the simple growths are not severe and consist 
mostly of heat and pruritus. In any case, the diagnosis can be 
made at once by a microscopical examination of the morbid tissue. 

Pathology. The morbid process producing these hyperplasia? 
is a form of inflammation with the production of new connective 
tissue, while congestion and exudative products are almost if not 
entirely absent, and is termed chronic productive or chronic cell- 
afar inflammation. Productive inflammation in mucous mem- 
branes and transitional cutaneous mucous membranes produces a 



LARGE HYPERTROPHIES OF THE VULVA. 387 

new growth of connective tissue in the stroma, occnrring diffusely 
or in the form of nodular polypoid outgrowths. A characteristic 
feature of this form of inflammation is its slow development and 
its tendency to persist for a long time. These general character- 
istics of productive inflammation agree very well with the clinical 
history and physical properties of the vulvar growths already 
described. 

The foregoing description applies only to the anatomy of simple 
hyperplasia?, which have thus been traced through all periods of 
their development and course. But it must be remembered dis- 
tinctly that hyperplasia in old syphilitic subjects presents precisely 
the same pathological appearances as in non-syphilitics. My aim 
has been to clear away all the darkness that has obscured these 
vulvar lesions, by showing that the majority of them are in no 
Avay specific or lupous in their nature, but that they are simple 
hyperplasia? which, owing to their situation, have undergone 
various changes. I have not attempted to portray the patho- 
logical anatomy of any of the syphilitic new growths, since that 
has been done by many, and it is not essential here. 

(For further microscopical details as to this morbid process, see 
my essay " On Chronic Inflammation, Infiltration, and Ulceration 
of the External Genitals of Women," New York Medical Journal, 
January 4, 1890.) 

Treatment. Thorough removal with the knife or with the 
galvano-cautery of these growths is always necessary, the incision 
being made with the view of preserving the conformation of the 
parts as much as possible. After operation, irrigation of the vagina 
and care as to the cleanliness of the vulva are very necessary. 



CHAPTEE XXXIV. 

INFILTRATION AND DISTORTION OF THE VULVA FROM 
CHRONIC CHANCROIDS. 

Hypertrophies of the labia majora and also of the labia 
minora, and of the deeper tissues, as the result of chronie chan- 
croids, are far from uncommon in hospitals for women suffering 
from venereal diseases. Anyone who has had large experience in 
the treatment of these ulcers in women will at once call to mind 
cases where, after the healing of the ulcer or ulcers, a persistent 
and rebellious thickening of the parts has remained. Time, care, 
and appropriate treatment will, in most cases, cause the disappear- 
ance of this residual thickening. But when patients are careless 
or refractory to treatment, uncleanly, and given to drink, the 
hypertrophy, if it has attained a moderate degree and extent, will 
almost inevitably increase. Then, again, we constantly find it per- 
petuated by gonorrhoea! and leucorrhoeal discharges. The foregoing 
remarks apply to conditions secondary to what we may call acute 
chancroids — that is, lesions which have come and have disappeared 
within one, two, or four months, for this form of ulcer is very 
persistent in women. 

In like manner hypertrophy of the vaginal introitus, vulvar 
and juxta-anal region is far from infrequent as a direct result of 
chronic chancroids. 

The history of a case will throw light on the course of this 
form of trouble : 

A domestic, aged forty-eight years, who never had syphilis, had 
a small chancroid just above the fourchette on the left labium 
minus, which had lasted nearly a year, when she entered the hos- 
pital. It then was an elevated ulceration (ulcus elevatum) on the 
inner side of the left nympha, about the size of a silver quarter. 
It showed no tendency to extend, but remained in an indolent 



INFILTRATION AND DISTORTION OF THE VULVA. 389 

condition, became hyperplastic and elevated. The corresponding 
nympha was very much thickened, hard, and elastic, and the hyper- 
plasia continued from it into the vagina for about an inch. The 
appearances are well shown in Fig. 80, which was made from a 

Fig. 80. 





Showing chronic chancroid of the left nympha, with hypertrophy of 
the deeper parts. 



photograph taken fifteen months after the chancroidal infection. 
It will be seen that the hyperplasia is well limited to the affected 
nympha. Though this woman received the utmost care from my 
internes and nurses, the ulcer healed very slowly, and it required 



390 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

a full year's treatment (for, contrary to the custom of these patients, 
this woman remained continuously in the hospital) to produce per- 
fect resolution in the nympha and to restore the elasticity of the 
introitus vaginae. 

The foregoing case was an especially auspicious one, as the 
woman was kept under treatment until she was cured. These 
women are usually very bad patients, and will only submit to 
treatment for short periods of time. 

The painlessness of the genitals in this condition is very sur- 
prising, and, although the ostium vaginae is often hard and rather 
unyielding, these women may continue to have promiscuous coitus. 
After the acute stage the hyperemia settles down into an indolent 
condition, which may thus remain indefinitely, or it may be suc- 
ceeded by an exacerbation of inflammation and ulceration due to 
drunkenness, debauchery, and general uncleanliness. Internal 
medication is powerless in these cases, and topical applications, 
which are slow to heal the parts in the early stage of the career 
of these women, in the latter periods have little and often no 
effect. As the trouble becomes chronic the whole vulva, more 
or less of the vagina, the anus, the rectum, the vesico-vaginal 
septum, and vagino-rectal space become inflamed and hyper- 
plastic, and, as a result, ulcerated. 

In general, chronic chancroids on the clitoris and external por- 
tions of the genitals heal readily, while those of the ostium vaginae, 
of the inner surfaces of the labia minora, and of the fourchette are 
often very difficult to cure, and they show a tendency to become 
chronic and to induce hyperplasia and hypertrophy of the parts. 
In the chronic stage, in proportion as the ulcers are deep and inac- 
cessible, and as they involve the natural outlets, they are menaces 
to life by the disastrous conditions which they lead to. 

Large or small fleshy masses, the result of an extension of the 
inflammatory process, may occur on the perineum or at the 
margin of the anus. Fleshy tumors and excrescences may also 
result from chancroids hidden in the puckered folds of the anus. 

Chronic chancroids with great vulvar hypertrophy are usually 
found in women beyond thirty and forty years of age. Such 



INFILTRATION AND DISTORTION OF THE VULVA. 391 

women, so long as they are in any way attractive to the male sex, 
remain in the hospital just long enough to become " patched up/' 
as we may say. In the early years of their trouble their general 
health does not suffer, and it is to the uninitiated a matter of sur- 
prise to see women with distorted, disfigured, and ulcerated vulvae 
complain so little, if at all, and seem so well. As time goes on, 
however, things change. Ulceration may perforate the urethra, 
the bladder, the vagina, and the rectum, and may also burrow 
and form large cavities which may open by fistulous tracts about 
the buttocks or thighs. Hemorrhages of greater or less severity 
may take place, and erysipelatous inflammation, beginning about 
the genital parts, may spread beyond and be accompanied by 
severe systemic reaction. Then, as years go by, signs of decay 
show themselves. The patients begin to cough and emaciate, 
and a rapid phthisis may end their misery. They may become 
attacked by affections of the kidneys and liver which prove fatal. 
Then, again, we constantly see these women fall into a condition 
of marasmus, over which treatment has no influence whatever. 
And, again, we see life gradually sapped by rebellious chronic 
diarrhoea or dysentery. I have seen several of these women 
carried off by well-marked pysemic infection. 

In a general way, I should say that women suffering from these 
severe forms of chronic chancroids and vulvar deformity, with all 
their dangerous concomitants, live from eight to fifteen years ; an 
average of ten years, I think, is quite constantly observed. 

Some patients are more prone to inflammation and irritation 
than others, and they may become the subjects of vulvar hyper- 
plasia. I have not been led to look upon a dyscrasia as an under- 
lying cause of any moment in any non-syphilitic cases. In my 
experience the vulvar troubles begin when the women are well, 
and ill-health overtakes them when the hypertrophies have led to 
ulceration, fistulas, deep abscess, fissures, and to strictures of the 
urethra and rectum, and stenosis of the vagina. 

It is important to remember that, though we use the term 
chronic chancroid, very many of the so-called ulcers do not pre- 
sent the typical and classical appearance of these lesions when of 



392 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

recent origin. Indeed, the term as applied to ulcers about the 
vulva is one of great elasticity, since almost any good-sized in- 
tractable ulcer is thus denominated. These ulcers present wide 
variations, since they may appear like ulcerated excoriations, they 
may present resemblance to the classic chancroids, and they may 
be covered with a greenish-brown or grayish-black film, or even 
with a layer of tenacious necrotic tissue. Their edges very fre- 
quently present nothing pathognomonic, and their secretion of 
pus and pus combined with molecular detritus, and even blood, 
will be offensive to the nose in proportion as patients are uncleanly 
and untreated. Some authors have laid much stress on the odor 
of the secretions in these cases of vulvar hypertrophy, but my 
experience teaches me that it conveys nothing of diagnostic im- 
port, but that all morbid secretions are exceedingly disgusting in 
unclean persons. 

In many instances the origin of these ulcers in a contaminating 
coitus is readily ascertained, while in others they seem to develop 
de novo. The truth of the matter is that in all cases of vulvar 
hypertrophy, particularly in the succulent stage, ulceration is liable 
to occur as a result of irritation or traumatisms of all kinds, and 
that they are undoubtedly caused by micro-organisms, which find 
a nutrient nidus in chronically inflamed tissues. 

In some cases we find hypertrophy precede ulceration, and in 
others that chronic ulceration leads to hypertrophy. As a general 
rule, however, hyperplasia is by far the more active and the ulcer- 
ative the less prominent process. It is remarkable to observe the 
great chronicity and indolence of these vulvar ulcers. They, as 
a rule, increase very slowly, and may remain many months, and 
sometimes one or two years, without any perceptible change. In 
these cases, however, the hyperplasia goes on more or less actively. 
The reason for the slow and indolent growth of these lesions lies 
in the fact that the condensation of the hyperplastic tissue offers, 
chiefly by its narrowing of the bloodvessels, a dense and unyield- 
ing soil for the destructive process. 

The inguinal ganglia in these cases are usually somewhat 
enlarged and sometimes much swollen. In some cases no change 



INFILTRATION AND DISTORTION OF THE VULVA. 393 

is noted in them, consequently they are not of much aid in diag- 
nosis. 

Treatment. When seen tolerably early chronic chancroids with 
vulvar hyperplasia should be treated systematically by means of 
frequent and copious injections of some antiseptic solution. 
Watery solutions of powdered borax (5iij to 5xxxij) with one 
drachm of carbolic acid should be used three times a day. The 
next essential is to keep the morbid surfaces separated as much 
as possible and in a dry condition. To this end tampons of 
absorbent gauze dusted with iodoform, boric acid, or aristol 
should be carefully applied and frequently renewed. 

When the surfaces of the ulcers are sluggish, fluid carbolic 
acid may be carefully and sparingly applied, and then the tampon 
may be inserted. When the surface is very necrotic or fungoid 
it may be necessary to curette the parts or to apply pure nitric 
acid very carefully. 

Whenever fleshy masses protrude so much that they cause 
discomfort, they should be removed with the knife. Should 
infection of the cut surfaces occur, the continuance of the regular 
treatment will soon abort this threatened complication. 



CHAPTER XXXV. 

HYPERTROPHIES OF THE VULVA DUE TO SYPHILIS. 

The vulva and anal region are not infrequently the seat of 
syphilitic lesions in the secondary and tertiary periods of the 
disease. 

Condylomata. 

In the secondary period it is not uncommon to find, particu- 
larly in uncleanly women, pinkish or red, broad, flat, fleshy 
disks of thickened tissue, which may become remarkably salient, 
as shown in Fig. 81, and sometimes may present a warty surface. 

Fig. 81. 




Showing condylomata of vulva and anus. 

Condylomata in the female may give rise to a viscid malodorous 
discharge, which, escaping down the thighs, causes much irritation. 

These lesions begin as one or two red eroded spots, in which 
hyperplasia soon develops, and then the condylomata increase in 



HYPERTROPHIES OF THE VULVA DUE TO SYPHILIS. 395 

size and in height, until large fleshy masses may be produced. 
These run an indolent course and may cause much distortion of 
the vulva and perineum. They usually yield quite promptly 
to treatment. In some neglected cases they lead to vulvar and 
vaginal deformity. 

Vulvar Deformities in the Early and Late Stages of Syphilis 
Due to Indurating (Edema. 

In some exceptional cases the initial sclerosis occupies a whole 
labium and much enlarges it. In a decided number of instances 
we find that accompanying the initial lesion, either around it or 
in its vicinity, a hard oedema of one labium or both labia occurs. 
This oedema, which has been called sclerotic or indurating, is very 
peculiar, and is the sole appanage of syphilis. It usually begins 
in an indolent aphlegmasic manner, without pain, and perhaps 
with no heat and pruritus, and becomes fully formed in from one 
to three weeks. Then, again, in some cases its onset is quite 
brusque and rapid, and in a few days a labium may be greatly 
enlarged. When such a labium is examined it may be found to 
be of double, even quadruple, its normal size. Its tegumentary 
covering may be normal in color or a little redder than usual, 
while its mucous membrane is of a dull red. In some cases the 
corresponding labium minus may be affected, and its pinkish -red 
color is then somewhat increased. There is no evidence of in- 
flammatory engorgement, nor of soft oedematous swelling. The 
parts are not unusually hot, not tender on pressure or otherwise, 
as a rule, but they are of an extreme hardness, sometimes pre- 
senting a dense elasticity, like one's ear, and again a stony feel, 
like cartilage or sclerodermatous tissue. The impress of the finger 
always meets resistance. It may be that the whole labium or the 
labia (if both are involved) may be thus uniformly sclerotic, or, 
as often happens, there may seem to be a central kernel of great 
density surrounded by an atmosphere of elastic firmness. In 
uncleanly women, during pregnancy, and as a result of trauma- 
tism, this indurating oedema may extend beyond the labial limits. 



396 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

Well-marked secondary symptoms are usually constant concomi- 
tants. 

The appearances of indurating oedema of both labia minora in 
late syphilis are well portrayed in Fig. 82. 

Fig. 82. 







Showing indurating oedema of both labia minora in late syphilis. 

Though indurating oedema is more commonly seen in the primary 
and early secondary stages of syphilis, it may occur later in the 
disease — namely, in the first, second, and even third years. In 
these cases of late development, however, there is commonly a 
marked persistence and activity of the diathesis. While the in- 
durating oedema of the primary and secondary stages of the disease 



HYPERTROPHIES OF THE VULVA DUE TO SYPHILIS. 397 

usually accompanies or follows the active lesions, that of the later 
periods may be unaccompanied by any previous or present syph- 
iloma. Though late oedema may be thus complicated by various 
syphilitic processes, it very often is developed by vaginal or 
vulvar irritation, and also by traumatism. 

Fig. 83. 




Showing indurating oedema of both labia majora, with warty and 
papillomatous growths. 

In some cases very much enlargement and distortion of the 
labia majora are produced by indurating oedema, and rather ex- 
ceptionally the surface of the new growth becomes warty and 
papillomatous. When this warty condition is found on these 
densely hard and indolent tumors the diagnosis of epithelial 



398 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

cancer may be made. In Fig. 83 a typical mass of indurating 
oedema is shown on which many warty growths had developed. 
Several physicians who saw this case at first thought it was one 
of cancer. 

Indurating oedema runs a long, sluggish course, and yields very 
slowly to treatment, which should be both local and general. In 
some cases ablation of the parts becomes necessary. 

Chronic Chancroids in Old Syphilitics. 

We frequently find in early syphilis and in later periods when 
the diathesis is active, and again when it is wanting, ulcers which 
appear de novo, and from tradition we call them " chancroids." 
It is to-day a generally accepted fact that chancroidal ulcers are 
caused by many forms of active pus, and that syphilis is a fre- 
quent cause of the secretion which gives rise to these ulcers. 
There undoubtedly exists in syphilitics a vulnerability of the 
tissues, showing itself in their tendency to ulceration and hyper- 
plasia. About the female genitals this tendency is shown in the 
development of chancroids upon parts irritated by uterine, vagi- 
nal, and vulvar secretions, and especially upon any lesion of con- 
tinuity, such as an excoriation, a tear, a fissure, or upon the seat 
of vesicles. In their early stages these ulcers may resemble the 
classical chancroid, but as they grow older they lose more or less 
of their typical appearance. 

These ulcers usually have sloping edges and fairly smooth bases, 
which are covered with a greenish-gray or brownish-red film of 
pus, under which is a slightly papillated surface. They look in- 
dolent, and their history proves that in general they are aphleg- 
masic, persistent, and chronic. They occur on all parts of the 
female genitalia, and may remain without any perceptible exten- 
sion for a long time, but yet they frequently cause great harm. 
As long as they remain they give rise to a very low grade of 
secondary inflammatory engorgement which leads to hyperplasia, 
which may extend up the vagina or into the vulva, thickening 
the vaginal and often the rectal walls, attacking the labia minora 



HYPERTROPHIES OF THE VULVA DUE TO SYPHILIS. 399 

by preference and causing their great hypertrophy, and also some- 
times inducing similar change in the labia majora. All of the 
clinical features of the vulvar hypertrophies which result from 
chronic chancroids may be produced by these chancroids of syph- 
ilitic origin ; therefore, having already described them, repetition 
is unnecessary. It, however, may be added with advantage that 
where the syphilitic diathesis is active, and often even when it is 
wanting, specific evidences of the disease may be seen elsewhere upon 
the body. The hypertrophies produced by these syphilitic ulcers 
are similar to those of simple chancroids, except that we sometimes 
see a greater tendency to destructive ulceration, and in some cases 
to phagedena. Though the clinical features of chancroidal and of 
this form of syphilitic sequelae are hardly sharply enough drawn 
to warrant separate descriptions of their respective hyperplasia, 
the underlying facts must be stated, and this necessitates the divi- 
sion I have made. Hypertrophy of the vulva, therefore, depend- 
ing on simple hyperplasia from chronic ulceration in syphilitic 
patients, is far from uncommon. 

Distortion of the Vulva in Old Syphilitics. 

There is a condition of the tissues in older syphilitics, and usu- 
ally in persons of the lower classes, which has not, according to 
my reading, been described by any author, but which, I am con- 
vinced from years of study, is not extremely uncommon about 
the genitals of women, particularly as seen in large venereal ser- 
vices. 

This condition consists in a simple hyperplasia of the tissues 
of the genitalia, which results in more or less deformity. While 
early in the disease we so commonly see the tendency to ulcera- 
tion, later in the diathesis it seems to engraft on these tissues a 
tendency to a very low grade of inflammatory process by which 
organs and parts are much thickened and distorted. This hyper- 
plasia in syphilitics is microscopically the same as that of non- 
syphilitics, and cannot in any sense be considered as an essential 
evidence of disease. 



400 SEXUAL DISORDERS OF THE MALE AND FEMALE, 

No systematic description can be given of these vulvar distor- 
tions, since no two cases are alike. In all cases the natural 
shape and relations of the parts are more or less enlarged and 
disfigured. 

On Plate XIII. is well shown the condition of the external 
genitalia in a twenty-eight-year-old woman who had had syphilis 
six years before this vulvar distortion had developed. At this 
time the following conditions were noted by me : The left labium 
minus was very greatly increased in length and thickness, the 
clitoris and its prepuce were much hypertrophied, and the right 
labium minus (which was originally much shorter than its fellow) 
formed a long, fleshy process, which hung down nearly two inches 
between the thighs. The appearances are well shown in the Plate, 
the hypertrophied growths being brought into prominence by 
means of threads. The mucous membrane of these parts was 
somewhat thickened and similar to integument. The whole mass 
was of a deep violet or purple-red color. At the base of these 
tumors were three shallow ulcers which might be taken for chan- 
croids. Eversion of the hyperplastic nymphse showed a thickened, 
violaceous condition of the whole vulva, with a decided narrowing 
of the vaginal orifice by reason of the thickening of the tissues, 
which extended into the vagina three inches. The orifice of the 
urethra was obscured by a cluster of hypertrophied caruncles. 
The labia majora were also enlarged and swollen, and the very 
short perineum ended in a tab- like mass of integument, seated 
just on the anterior border of the anus, but not encroaching upon 
it. From the stenosed vaginal orifice a copious persistent dis- 
charge escaped. The hypertrophied nymphse presented a firm 
resistance to pressure, and the tissues of the vulva, though rather 
more dense than normal, were, as we may term it, in a succulent 
condition from the hyperemia. The ulcerations were rather 
superficial, of brownish-red color, smeared with pus, smooth of 
surface, without well-defined outlines, and their margins devoid 
of any appearance of being undermined. There was little or no 
pain in the outer growths, though the vulva was rather tender, 
and sometimes, when irritated, the seat of a stinging, smarting, 



PLATE XIII. 







Hyperplasia of External Genitals in an Old Syphilitic 



HYPERTROPHIES OF THE VULVA DUE TO SYPHILIS. 401 

and itching pain. The sufferings of the patient, however, did 
not seem to be at all proportionate to the severity and extent of 
the morbid process. She had at times been treated energetically 
with antisyphilitic remedies with no effect whatever. I ablated 
the external tumors, greatly to the relief of the patient. Later on, 
hot antiseptic injections and appropriate topical treatment cured 
the ulcers and lessened the vulvar hyperplasia. The woman left 
the hospital much improved. 

It is interesting to note that during the three or more years in 
which the vulvar hyperplasia was going on in this woman she 
suffered very little from the local affection. The progress of its 
development was slow, aphlegmasic, and unattended with any 
constitutional reaction. Microscopical examination of the re- 
moved masses showed that their structure was identical with that 
of hyperplasia occurring in non-syphilitic women. 

Distortion of the Vulva, with Destructive Ulceration. 

When the genitals are the seat of hyperplasia in non-syphilitic 
women ulceration may occur, but it is commonly limited in extent 
and not very destructive in tendency, though from the nature of 
the parts such damage may be done in these cases as will lead to 
invalidism and death. In chronic chancroid the ulcerative ten- 
dency is sometimes well-marked and even quite destructive. In 
syphilitic subjects with these hyperplasia? the acme of disintegra- 
tion is often observed. In them, as a rule, the ulcerations are 
more active and extensive than in non-syphilitics. Xot only do 
we find severe ulceration in syphilitic subjects, but also phagedena, 
which may cause terrible destruction of the affected parts. 

In Fig. 84 are shown the external genitalia of a woman, thirty- 
two years old, who became syphilitic when twenty-two. Seven 
years after infection, not having suffered from any manifestation, 
nor having presented any evidence of the disease for three years, 
she, after an attack of vaginitis, observed that her vulva became 
gradually swollen. This hypertrophy went on for three years, 
when it presented the appearances shown in Fig. 84. At this 

26 



402 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

time she became much debilitated and took stimulants and opiates. 
While she was in this state ulceration began in the vulvar ellipse 
and destroyed considerable of the hyperplastic tissue. Having 
built her up with tonics and generous diet, and nearly cured the 



Fig. 84. 




Showing hyperplasia of vulva and perineum and destructive 
ulceration in an old syphilitic. 

ulcers, I removed the hypertrophied masses and obtained a very 
favorable result from cicatrization. Microscopical examination 
of the new growths showed simple hyperplasia. 

In rare cases phagedena may attack these vulvar tumors, par- 
ticularly when the patient is getting on in years, is unhealthy, and 



HYPERTROPHIES OF THE VULVA DUE TO SYPHILIS. 403 

uncleanly. The course and results of phagedena in an old syph- 
ilitic in whom vulvar hyperplasia was present are well shown in 
Fig. 85 and by the following details of the case : A woman, aged 
forty-seven, had had for years great hyperplasia of the vulva fol- 
lowing syphilis contracted ten years before. When she was in a 
dissipated and woe-begone condition, ulceration began about the 
fourchette. This lasted several weeks, and then the parts began 
to melt away from phagedena, with the result depicted in Fig. 85. 

Fig. 85. 




Showing great destruction of hypertrophied vulva and perineum 
of an old syphilitic. 

Under treatment, healing was induced, cicatrization took place, 
and a fairly good condition of the parts was left, incontinence of 
the feces being the most distressing symptom. 

The ultimate outcome of hyperplasia of the vulva in old syph- 
ilitics is about the same as that already sketched of the declining 
days of patients suffering from chronic intractable chancroids of 
that region. 

The chronicity and inveterate course of these vulvar hyperplasia 
are undoubtedly due to the structural peculiarities of the vulva, 



404 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

to its excessive vascular and nervous supply, to the conditions to 
which it is so constantly subjected, and to its dependent position 
compressed between the thighs. Except in the mouth (and that 
very rarely), we do not see such persistent and deforming low- 
grade inflammation and hyperplasia. 

In the past these chronic deforming lesions of the vulva, whether 
due to chancroids or in old syphilitics, were fancifully called by 
the following terms : lupus hypertrophicus et tuber vsus, lupus ser- 
piginosus, and lupus prominens, esthiomSne hypertrophique oede- 
mateux et vege'tant, perforating lupus, and esthiomSne perforant de 
Vanus et de la vidve. 

Treatment. Condylomata lata of the vulva and perineum 
should be treated both locally and systematically. The first 
essentials of treatment are absolute cleanliness of the genital 
tract and a condition of dryness of the parts. Alkaline and anti- 
septic irrigations should be used freely and frequently. When 
the parts are dried they should be well dusted over with a powder 
composed of calomel and oxide of zinc, of equal parts. Then care 
should be exercised in keeping surfaces which tend to coapt as 
much apart as possible by means of sterilized absorbent-gauze. 

When condylomata lata have become warty on their surface it 
may be necessary to apply very carefully and sparingly fluid car- 
bolic acid, or even nitric acid in rebellious cases. When involu- 
tion of the lesions is well under way a powder of oxide of zinc 
and boric acid (equal parts) may be used. 

Systemic treatment may be administered in the form of mer- 
cury by the mouth or by inunction or injection, or by the use of 
the mixed treatment. 

Indurating oedema of the vulva and the perineum is usually 
very persistent, even when active treatment is instituted. Clean- 
liness and dryness of the parts are absolutely necessary. Mercu- 
rial ointment, strong or mild, may be applied and kept on these 
growths, and thus, with the internal use of mercurials, perhaps 
in combination with the iodide of potassium, we may cause reso- 
lution after a time. When indurating oedema attacks protruding 
parts or those which can be removed without destroying the con- 



HYPERTROPHIES OF THE VULVA DUE TO SYPHILIS. 405 

formation of the vulva, therapeutics having failed, it is well to 
resort to the knife, treating the case with all antiseptic require- 
ments. 

Chronic hyperplasias of the vulva, vagina, and perineum are 
always absolutely uninfluenced by local or general mercurial treat- 
ment. The best results follow the ablation of all prominent 
masses. Then healing may be induced, and though a more or 
less stenosed vaginal orifice and vulva may be left, the patient is 
at least more comfortable and not in so much danger of ulcera- 
tion, abscesses, fistulas, and septic complications. 



CHAPTER XXXVI. 

TUBERCULOUS ULCERS OF THE VULVA. 

The fact is now so well established that tuberculosis not very 
infrequently attacks the skin that the probability of the develop- 
ment of the tuberculous ulcers upon the outer genitalia of the 
female can no longer be called in question. 

It may be stated as a broad fact that tuberculosis of the female 
genitalia grows progressively more uncommon in occurrence as it 
descends from the ovaries, the tubes, and the uterus into the 
vagina and vulva. Tuberculosis of the vagina by extension of 
the process from above can hardly be called very rare. In- 
volvement of the vagina alone is far from common, and when 
it does occur in some cases the vulva may be more or less in- 
volved. 

I have seen three cases in which ulcers began just beyond the 
external genital regions, and in their extension involved the vulva, 
and of which the clinical diagnosis was tuberculosis of the skin 
and mucous membrane. These ulcers had finely and coarsely 
granular, papillomatous, and even fungating surfaces, and were 
encircled by hard, somewhat everted, deep-red and even bluish- 
red margins, with irregular and somewhat festooned outlines, and 
they secreted an abundance of pus. They began as round or oval, 
deep, violaceous red tubercles, which soon broke down into ulcera- 
tion. In former years we classed these lesions under the head of 
scrofulide tuberculeuse ulcSreuse, proposed by Hardy and Bazin. 
Two of my cases occurred before we knew of the existence of 
the bacillus tuberculosis, while from the third and more recent 
case I was unable to excise a portion of the morbid tissue for 
examination. The patient, however, had pulmonary phthisis. 

Primary tuberculosis of the vulva, however, is rare, and the 



TUBERCULOUS ULCERS OF THE VULVA. 407 

most satisfactory case of it on record is that of Deschamps. 1 
Zweigbaum's case 2 has been spoken of as being rare and peculiar. 
It is rare in the sense that tuberculosis of the female genitalia is 
rare. The details of it show that the morbid process began in 
the uterus and extended downward to the vulva. Chiari's case 3 
seems to have been one of tuberculous infection of the vulva, with 
involvement of the vagina. 

If it is worth while to preserve the term lupus of the vulva, it 
may be applied to cases of ulcers caused by the tubercular bacillus. 

Treatment. These tubercular ulcers should be curetted and 
dressed with balsam-of-Peru ointment. They heal very slowly 
and are prone to relapse. 

The general tuberculous condition of the patient should be care- 
fully treated, and if possible she should have an appropriate change 
of climate. 

1 "Etude sur quelques ulcerations rares et non-veneriennes de la vulve et du 
vagin." Archives de Tocologie, January, February, and March, 1885. 

2 "Ein Fall von tuberculoser Ulceration der Vulva, Vagina, and der Portio 
Vaginalis." Berlin, klin. Wochenschrift, May 28, 1888. 

3 ' ' Ueber den Befund ausgedehnter tuberculosen Ulceration in der Vulva und 
Vagina." Vierteljahr. fur Derm, und Syph., 1886, Band xviii. pp. 341 et seq. 



CHAPTER XXXVII. 

A PECULIAR NEW GROWTH OF THE VULVA. 

There is a form of new growth of the vulva, which was first 
described by me 1 several years ago, which presents many peculiar 
and interesting features. I have had three cases of this trouble, 
but I shall in this chapter only describe two, since they contain 
all the essential facts. The first case was that of a woman who 
was perfectly healthy until her thirty-fifth year. From the time 
of puberty she performed the duties of a domestic, and had inter- 
course, more or less frequently, with different men. In July, 1876, 
she was treated in Charity Hospital for a suppurating bubo of 
the left groin, which, being incised, left a characteristic cicatrix. 
The patient had no knowledge of an ulcer upon the external 
genitals. Early in the year 1877 she again entered the hospital, 
suffering from a large chancroid in the sulcus between the left 
labia majora and minora. This ulcer was markedly persistent in 
its course, but was finally healed. At this time she remained in 
the hospital eight months. Neither at that time nor in later or 
recent years could I discover any history or evidences of syphilis, 
nor did the patient present any syphilitic lesions during a period 
of over twelve years. It may be stated, therefore, as beyond 
doubt that she was free from that disease. 

On her discharge from the hospital in August, 1877, the patient 
was in excellent health ; she had no vaginal discharge, and a red- 
ness of the left side of the vulva was the only sign of her previous 
trouble. At this date she was rather more than thirty-six years 
of age. 

During the autumn of 1877 the patient suffered from excoria- 
tions of the vulva about the seat of the already mentioned chan- 

1 American Journal of the Medical Sciences, February, 1890, and January, 1894. 



A PECULIAR NEW GROWTH OF THE VULVA. 



409 



croid. This part was noticed to be red and tender, and to be the 
seat of slight oozing of blood, particularly after hard work, fatigue, 
and the menstrual epoch. In consequence of this irritated and 



Fig. 86. 




Showing the new growth in period of full development. 



somewhat painful condition of the vulva the patient never after- 
ward had sexual intercourse. 

During the succeeding nine years she worked as a domestic. 
She was fairly clean in her habits as a rule, but during periodical 



410 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

drunken debauches she was careless as to the condition of her 
genitals, and in consequence thereof she had numerous attacks 
of varying severity of acute and subacute vulvitis. During all 
these years it seems clear from her story (which was elicited at 
various times with careful minuteness) that she suffered from an 
inflamed and excoriated condition of the left side of the vulva, 
which was subject to exacerbations and periods of quiescence ; as 
a result of this long-continued condition of irritation an anomalous 
form of new growth developed. 

The appearances of this peculiar new growth are well shown in 
Fig. 86, which was made about two and a half years after the 
date of its beginning. It will be seen that the normal appearances 
of the vulva are wholly lost. There are no traces of the labia, 
large or small. The clitoris is represented by a central mass of 
cicatricial tissue, and the introitus vaginae looks like a ragged slit. 
The perineum is also invaded with processes of the new growth 
jutting backward. Extending from the vulva the disease is seen 
to invade the pubes and the right groin, and to extend downward 
over the skin of the fork of the thighs. In no place is there 
evidence of tumor-like formation, as the new growth is every- 
where developed en surface ; in other words, it is flat in structure. 
The surface of this neoplasm is of a maroon or chocolate color, 
with considerable glossiness. At times this morbid surface was 
perfectly dry, and at other times it gave issue to a thin, scanty, 
reddish serum. 

The parts present a firm but decidedly elastic feeling, as if the 
new growth possessed a fair amount of density. To the eye and 
to the finger-tip it is evident that the vulvar and extragenital 
portion of the new growth is uneven and thrown into slight irreg- 
ular folds — a condition due undoubtedly to the natural conforma- 
tion of the parts. Radiating from the clitoris region is a quite 
well-formed sheet of cicatricial tissue, and scattered on the outer 
and upper parts of the new growth are irregular shaped islets of 
the same. Upon the lower part of the vulva and toward the 
perineum the mode of extension of the new growth is well shown. 
On the right side it juts outward by an abrupt semicircular ele- 



A PECULIAR NEW GROWTH OF THE VULVA. 411 

vated margin, while on the left side the morbid tissue ends in a 
similarly sharp festooned outline. In the upper and older parts 
of the morbid area the sharpness of the marginatum is lost in 
cicatricial tissue, and elsewhere as a result of the treatment adopted. 
At the time the drawing from which Fig. 86 was made the morbid 
process stopped at the orifice of the vagina, which, however, was 
somewhat contracted. Toward the end of life the new growth 
became so copious and firm in this region that this orifice would 
only admit, and then with considerable pain, a soft bougie of about 
No. 26, French scale. There was never any evidence of stricture 
of the urethra. Besides the foregoing appearances, there was evi- 
dence in life of a marked condensation and contraction in all of 
the affected parts, which increased very slowly and imperceptibly. 
The salience of the vulva was, in the end, wholly lost, and ex- 
amination of the new growth en masse showed that it was quite 
firmly adherent to the deeper parts. When the patient was on 
her back the genitalia had a peculiar, flat appearance, and, as she 
stood up, it was evident that the labia majora no longer protruded 
between the thighs. 

This new growth began as a thickened, slightly elevated patch, 
of deep-red color, upon the left small and large labium. From 
this region it extended by peripheral increase toward the vaginal 
orifice, over the clitoris and upward and downward on the right 
side, while on the left it jutted down to near the anal orifice. The 
increase in area took place slowly, and as the new morbid tissue 
was formed, the older portions remained without any visible 
change, ulcerative or reparative. A slight amount of heat, pain, 
and pruritus were felt at irregular periods. The local symptoms, 
however, were for a long time so mild in character that the patient 
made little complaint. She could sit, walk, move, and lie down 
with little discomfort. Later on this was all changed. 

This form of new growth, it seems, is not peculiar to mucous 
membranes alone. By its peripheral increase it involves the skin, 
and by it its progress on this tissue may be accurately studied. 
We find on the integument the same flat form of new growth 
seen on the mucous membranes. The surface is smooth, even, 



412 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

and glossy, and the color a decided maroon. The elevation of 
the patches is from one to three lines, and they end by a well- 
defined, curved or festooned border, which, rounding off sharply, 
is lost in the sound skin. 

The elasticity of the infiltration remained for indefinite periods, 
and was slowly and gradually replaced by a marked condition of 
condensation, particularly in the central vulvar region. The 
result was that the conformation of the genitals was more and 
more destroyed. 

As the new growth infiltrates the tissues it is noticed that, when 
condensation takes place, the morbid areas become more or less 
attached to the bony or aponeurotic parts beneath until, in the 
end, they may feel as if soldered to them. Along the vulvar 
sulcus, where the disease originally began, the tissues presented 
to the finger-tip an almost brawny sensation, whereas, at the 
periphery of the new growth, well-marked but still decidedly 
firm elasticity was noted. 

On the mons veneris and the thighs evidences of healing were 
very often noted. This process usually began in spots of pearly 
cicatrization, which increased under favorable circumstances, until 
sometimes large healed areas were produced. But the cicatricial 
tissue always showed a great lack of vitality and endurance. So 
long as great care was observed, and the parts were kept scrupu- 
lously clean and dry, the healed surfaces might remain intact. 
But any inattention (from indifferences of the nurse, during the 
menstrual epoch, or a drunken debauch) was inevitably followed 
by retrogression. It was surprising to see how rapidly the cica- 
tricial tissue melted away. A part which was pretty well healed 
one day might a day or two later present the most typical morbid 
appearance. It was always evident that in healing, though the 
superfices of the morbid tissue became cicatrized, the deeper parts 
remained unaltered. Thus the disease oscillated between a cica- 
trized condition and the reverse month after month, in spite of 
the most careful treatment. 

The tendency to healing, however, was only observed in the 
juxtagenital parts just mentioned. At no time could we produce 



A PECULIAR NEW GROWTH OF THE VULVA. 



413 



reparative changes on and within the vulva proper. There the 
secretions and the close coaptation of the parts wholly prevented 
cicatrization, even though the greatest care was paid to place inter- 
posing absorbent dressings. As time went on the condensation 
of the vulvar and vaginal tissues was so great that the vulva was 
converted into a raw slit of tough tissue, the lips of which were 
drawn more and more tightly together, and the vaginal orifice 
almost completely stenosed. This state is well shown in Fig. 87, 

Fig. 87. 





Showing the condition of the genitals three months before death. 

which was taken about three months before death. It is inter- 
esting to study this picture in connection with Fig. 86. It will 
be seen that in rather more than two years the disease has ex- 
tended somewhat in an outward and backward direction. It is 
evident, however, that the luxuriance of the infiltration shows 
itself by involving the tissues in their whole thickness and depth, 
rather than by peripheral extension. The new growth showed a 
tendency to remain localized to the vulvar and juxtavulvar regions. 



414 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

During its whole course this new growth showed no tendency 
to luxuriate upon the surface. There was never any evidence of 
tumor-like formation, since the infiltration never reached a greater 
height than three lines. There is never any evidence whatever 
of ulceration, and though the morbid growth may, in more or 
less degree, become less salient, the decrease in its height was due 
to the slow and almost imperceptible melting away of its superfices 
and to its inherent, slow, contractile tendency. Further than this, 
it was observed that in the recesses of the vulva where the lesion 
was thrown into anfractuosities there was not the slightest ulcera- 
tion between its clefts and folds. It never presented any appear- 
ance resembling papillomatous outgrowths. 

Though this inflammatory and infiltrative process lasted many 
years, it did not seem to involve the contiguous lymphatic system. 
In both of my cases the ganglia were slightly larger than normal, 
but in none of them was there at any time any evidence of in- 
flammation. There was an entire absence of erythematous and 
erysipelatous complications. 

The disease shows no tendency whatever to malignant degen- 
eration, and of itself seems to have no direct influence upon the 
general economy. 

As I have already stated, the local symptoms were for a long 
time mild in character, and the patient made little complaint. 
Gradually, however, as the disease progressed without any abate- 
ment, the soreness in the parts was replaced by pain, particularly 
on the slightest movement. Walking became almost impossible, 
the erect position of the body could only be maintained with the 
greatest difficulty and discomfort, and as sitting became painful 
and almost impossible, the patient was forced to take to her bed. 
Even in the recumbent position all movements caused uneasiness 
and pain. The swollen, contracted, and excoriated condition of 
the vulvar sulcus impeded urination ; the stenosis of the vaginal 
orifice prevented the use of cleansing and soothing injections and 
impeded menstruation, while the rigidity and irritated condition 
of the parts prevented the application of absorbent tampons. In 
this hopeless, bedridden condition the patient was a pitiable object. 



A PECULIAR NEW GROWTH OF THE VULVA. 



415 



Her sufferings, pain, and worriment of mind led to utter demor- 
alization , marasmus, and death. 

A second case observed by me was in appearance and histologi- 
cally the same as the one already detailed. It was that of a 
widow, aged twenty -five years, of remarkably healthy parentage, 

Fig. 88. 




Showing the new growth of second case in its active stage. 



was well developed and tolerably strong, and measles in early in- 
fancy was the only sickness she could remember. When twenty- 
two years old she was married to a sailor, who seemed to her to 
be a perfectly healthy man. In the second year of her marriage 
(fully four months after the accidental death of her husband) she 



416 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

noticed a small pimple in the right inguinal fold at about the 
centre. This pimple gave her no pain and discharged no pus. 
In three months it had increased and formed a circular patch one 
and a half inches in diameter, with an exulcerated surface, and 
raised about an eighth of an inch above the normal plane of the 
skin. This new growth steadily increased in size, running down 
on the outside of the right labium majus, and involving it and 
the corresponding nympha, then gradually it extended downward 
and backward, encircling and involving the anus well in toward 
the sphincter. From this region it ran up the outer side of the 
left labium majus, attacking and destroying, or causing to melt 
away, part of it and then the whole of the corresponding nympha 
and ending at the left inguinal fold. The appearance of the parts 
is very clearly shown in Fig. 88. The new growth was sharply 
marginated by an elevated border nearly a quarter of an inch in 
height, beyond which the skin was somewhat pigmented, but 
seemingly healthy. The surface of the new growth was purplish- 
red in its oldest parts and at the periphery, and of a dull pinkish- 
red in its centre. The vulva was a raw, oozing slit, but it would 
admit with little uneasiness the first joint of the index finger. 
The anus was wholly involved, its tissues much condensed, and 
it was raw, sore, and painful on defecation. The surface of this 
new growth was similar in its nature and character, but was 
rather more uneven and more mammillated than the previous 
case. It gave issue to a scanty serous and serosanguinolent dis- 
charge. In its early months this new growth was the seat of 
ephemeral, throbbing pain, but in general, though it caused some 
discomfort and uneasiness on urination and defecation, it could 
not be said to be painful. 

Early in her hospital days we gave this woman a thorough and 
vigorous antisyphilitic course of treatment as a tentative measure. 
She bore the medication very well, but her vulvar lesion remained 
unaffected. We tried all sorts of local applications — antiseptic, 
astringent, and stimulating — without much success. We observed 
signs of improvement, and then came relapse. In this way about 
ten months slipped by, when, as a last resort, mercurial ointment 



A PECULIAR NEW GROWTH OF THE VULVA. 



417 



was applied to the surface, and healing slowly but surely began. 
In two or three months the parts were fully cicatrized, but the 
introitus vagina? was very much lessened in diameter, and the 
anus was rather rigid and less distensible than normal. 

The most thorough examination and searching inquiries were 
made to ascertain whether the case was of syphilitic nature, but 
in the end I became convinced that the woman never had had 
syphilis. 

Fig. 89. 







Showing a topographical view of the lesion. 

a. Epidermis irregularly thickened by ingrowths of the interpapillary portions 
of the rete Malpighii. 

b. Layer of granulation tissue. 

c. Lymph-spaces of the deeper subcutaneous tissue filled with granulation 
tissue. 



Microscopical Examination and Pathology. Portions of the 
new growth, in its fall thickness, excised by me from both cases, 
were examined by Dr. Ira Van Gieson, by whom the drawings 
(see Figs. 89 and 90) were made. The tissue was composed of 

27 



418 SEXUAL DISORDERS OF THE MALE AND FEMALE. 



three layers: (1) A superficial layer corresponding to the cutis, 
which is irregularly thickened by a considerable ingrowth of the 
Malpighian layer; (2) beneath this, replacing the corium and a 
portion of the subcutaneous tissue, is a layer of tissue apparently 
identical with granulation tissue, except that in places it contains 
large numbers of free red blood-cells ; and (3) a third layer corre- 
sponding to the deeper subcutaneous tissue, whose lymph-spaces 
are filled and distended with small round and small polyhedral 
cells. (Fig. 90.) 



Fig. 90. 



&m 










%^> 



Showing the distention of the deeper subcutaneous lymph-spaces with the 
granulation tissue. 

Where the nodule became continuous with the surrounding 
skin the cutaneous lymph-spaces were also filled with small 
round and polyhedral cells. 

There were no bacteria of any kind in any of the numerous 
sections. 

The results of this examination, therefore, seem to warrant the 
opinion that this chronic and incurable lesion consisted of simple 
local inflammatory tissue, which extended quite extensively into 
the subcutaneous lymph-spaces. 



A PECULIAR NEW GROWTH OF THE VULVA. 419 

When we consider the disastrous results produced by this 
growth it seems almost incredible that it should belong among 
the recognized simple and benign new formations. Though pos- 
sessing no malignancy, it led in the region affected in one case to 
as much suffering and to as deadly results as true malignant new 
growths are known to produce. The conformation of and the 
conditions inherent to and acting upon the external female geni- 
tals are undoubtedly the underlying causes of the chronicity of 
the inflammation. 

Our knowledge of the behavior of inflammatory tissues in gen- 
eral may be used in the present instance in explaining the varied 
conditions which are observed in the new growths. In its soft 
elastic stage it consisted of the elements already mentioned. 
Later on, where the conditions would admit of it, healing occurred 
by the production of fibrous tissue out of the abundant infiltrating 
granulation cells. Upon the juxta-pudendal regions — mons ven- 
eris and thighs — this change resulted in true, but ephemeral cica- 
tricial tissue. In the vulvar circle, fibrous tissue was formed out 
of this granulation tissue, and it produced in the new growth the 
density and contractility which were observed to appear as the 
process grew old. But here surface-healing did not occur. How 
far the color of the new growth was due to the red blood-cells 
which escaped from the new and thin capillaries we are unable 
to say. 

It seems strange that such an active inflammatory process 
should increase so slowly and show such a slight tendency to 
grow outward. 

Etiology. The exclusion of syphilis as the cause of this new 
growth is warranted not only by the absence of any history of 
that disease, but by the anatomical structure of its tissues. Tuber- 
culosis is, also, etiologically out of the question, by reason of the 
clinical and microscopical facts adduced. Though prolonged 
search was made for bacteria, none were found. For these reasons, 
therefore, we are warranted in concluding that the lesion was not 
a local expression of a general infective process, nor a result of 
a local infection. 



420 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

My studies convince me that the local inflammatory condition 
engrafted upon the vulva by the chancroidal ulceration led to the 
occurrence of chronic vulvitis, and that this affection was the 
starting-point of the inflammatory new growth of the first case. 
Anyone who has seen a considerable number of cases of chan- 
croids in women will recall instances in which the resulting in- 
flammatory thickening of the tissues was even more difficult to 
cure than the original ulcers. Though I look upon the ante- 
cedent chancroid in the first case as the pathological forerunner 
of the new growth, in the second I could not discover any special 
or specific cause whatever. The chancroidal ulceration induced 
a tendency to inflammation which remained long after it had lost 
its virulent nature and had healed. A virulent, ulcerative, and 
inflammatory process existed and was cured, but left in its wake 
a predisposition to simple local inflammation, which the nature 
of the parts and the uncleanly and disorderly habits of the patient 
tended to perpetuate. The resulting inflammation w r as in no 
degree complicated with an ulcerative tendency. In the second 
case the new growth began as a pimple in the groin, which was 
probably subjected to irritation. 

Diagnosis. The clinical features of this new growth are pecu- 
liar and distinctive. I know of no affection which resembles it 
in course or appearances. At the first glance chronic serpiginous 
chancroid may suggest itself to the mind. It was different in all 
its features from syphilitic lesions of the skin and mucous mem- 
branes, and, though to superficial examination the idea of lupus 
might suggest itself, a little reflection would convince the observer 
that neither in development, course, clinical features, nor micro- 
scopical anatomy was it like that disease. It has no appearances 
in common with epithelioma. So well marked and peculiar are 
the characteristics of this new growth that anyone familiar with 
its description will readily recognize it. 

Prognosis. The outlook in this disease is far from satisfactory. 
It is possible that if seen in the early stage of its course it might 
be arrested and cured, but when it has attacked the deeper por- 
tions of the vulva little hope can be entertained. 



A PECULIAR XEW GROWTH OF THE VULVA. 421 

Treatment. In the first case the new growth had attained 
such proportions when seen that palliative or destructive methods 
of treatment were out of the question. Various agents were used 
to induce healing, the most efficient of which were iodoform and 
bismuth and iodoform combinations. When perfect cleanliness 
was obtainable these drugs, applied on absorbent gauze and sup- 
ported by gentle but firm pressure of a bandage, usually did good. 
Unfortunately, this treatment could not be efficiently used in the 
vulvar sulcus, so that little progress was made there at any time. 
Though cicatrization was very often induced upon the juxta- 
pudendal portion of the growth, it never lasted for a long period. 
In short, though of simple and benign nature, this new growth is 
as rebellious to treatment as are the most malignant forms. It, 
however, may be said with some satisfaction that it does not give 
rise to the secondary metastatic growths which are such frequent 
complications of the latter. 

Systematic local and general antisyphilitic treatment was once 
carefully followed as a tentative measure, for some months, but 
no improvement whatever was produced. In this first case the 
applications of mercurial ointment increased the irritability of the 
parts and the suffering of the patient. 



CHAPTER XXXVIII. 

KRAUROSIS VULVAE. 

This rather rare affection, which is also called " serpiginous 
vascular degeneration of the nymphse " and " progressive cutaneous 
atrophy of the vulva," is observed chiefly in women of advanced 
life, but cases have been reported in which the disease began about 
the thirtieth and fortieth years. It is a disease of chronic, persist- 
ently progressive development, and results in much destruction of 
the tissues of the external genitalia. During its course it renders 
coitus painful and often impossible, and when the destructive 
changes have become fully developed intromission of the male 
organ is wholly impracticable. 

This morbid condition begins with soreness, pain, and pruritus 
about the small and large labia, which are either continuous or are 
subject to more or less severe exacerbations. In all cases the 
parts are very sensitive to the touch. In some cases the pruritus 
is so severe that the patients vigorously scratch and tear the parts, 
and this leads to an intensity of their disorder. 

In most cases the disease begins about the region of the clitoris, 
and from there extends over the whole external genitalia ; but in 
some cases its development is unilateral. 

When first seen kraurosis of the vulva appears in the form of 
one or many rather small areas of thickened and reddened mucous 
membrane, which is of a bright-red and even purple color. These 
chronically inflamed areas in the course of time become gradually 
more and more blanched, until in the end they are shiny white 
and scar-like. As one group of these areas is becoming pale and 
atrophied, new red inflammatory ones form, until in the end the 
whole vulva is the seat of a firm fibrous membrane, which may 
be traversed by scar-like bands, which are particularly well 
marked around the vaginal orifice. The original intensity of the 



KRAUROSIS VULVAE. 



423 



morbid process is in the tissues of the clitoris, around the urethral 
orifice, and the introitus vaginae. From these centres they 
extend outward and forward toward the anus, which becomes 
encircled by the atrophic process. When the inflammatory con- 
dition attacks the small nymphse they are at first somewhat in- 



Fic;. 91, 




Showing affected area, with contracted vaginal orifice. 
( After Baldy and AVilljams. ) 

creased in size, but when atrophy begins to develop they gradually 
melt away and become continuous with a similar condition of the 
internal surfaces of the labia majora. 

A very graphic illustration of this destructive vulvar affection 
is shown in Fig. 91. It will be seen that the urethral orifice is 



424 SEXUAL DISORDERS OF THE MALE AND FEMALE. 

yet patulous, but that it is surrounded by the expanse of fibrous 
membrane, which has so stenosed the vaginal orifice that only the 
tip of the little finger could be introduced a very short distance. 
The anal orifice was likewise contracted, but its function was not 
impaired. 

Etiology. No scientific statement can be made as to the cause 
of the affection. It seems certain that syphilis is not in any way 
an etiological factor. Whether vaginal discharges or irritative 
conditions of the external female genitalia, which may lead to 
pruritus and dermatitis and the consequent scratching and bruis- 
ing of the parts, are the exciting causes, it is impossible to say. 
It has been suggested that (1) removal of the uterine appendages, 
(2) artificially induced menopause, and (3) disease of the periph- 
eral trophic nerve-filaments may be the etiological factors ; but 
no precise statements can be made. 

Pathology. The disease is essentially a chronic hyperplasia 
of the subcutaneous tissues and corium, which later on undergo 
atrophy, with the formation of scar-tissue and shrinking of the 
vulva. An exhaustive study of this subject, illustrated with 
microphotographs, will be found in the essay of Baldy and 
Williams. 1 

Treatment. In the early stages of kraurosis vulvae care 
should be taken that all irritating secretions shall be systemati- 
cally treated and that frequent antiseptic vaginal douches shall be 
used. Locally soothing applications to pruritic and inflamed areas 
should be used in the shape of ointments or lotions of carbolic 
acid, cocaine, eucaine, antipyrine, iodoform, ichthyol, according 
to indications. In some cases watery solutions of nitrate of silver, 
of the strength of 5 per cent., or of permanganate of potassium, 
2 per cent., may give ease and comfort when pruritus and derma- 
titis are troublesome. When the disease is fully developed it may 
be necessary, after proper preparations of the patient under strict 
antisepsis, to dissect out the scar-tissue from around the vaginal 
orifice as far down as the margin of the anus, and then to approxi- 

1 American Journal of the Medical Sciences, November, 1899, pp. 528 et seq. 



KRAUROSIS VULVAE. 425 

mate the healthy skin and mucous membrane by means of continu- 
ous and interrupted sutures of silk or silkworm-gut. The vagina 
should be packed with iodoform gauze and sterile gauze, held in 
place by means of a T-bandage. The patient should be catheter- 
ized at each dressing. As a result of this operation the patulous- 
ness of the vaginal orifice has been restored and satisfactory coitus 
has been rendered possible. 



INDEX 



AMPULL ACTIONS, deferential, and 
aspermatism, 197 
inflamed, secretions of, 271 

of vasa deferentia, 50 
Amyloid bodies in prostate, 252 
Anaemia and sterility in female, 347 
Anatomy of chronic bulbous ure- 
thritis, 209 

of Littre's follicles, 36 

of prostate gland, 39 

of prostatic urethra, 40 

of seminal vesicles, 47, 70 
Anterior urethra, 29 
Anteversion and sterility, 349 
Anthropophagy, 343 
Arteries of penis, 21 

of prostate. 43 
Aspermatism, 197 

anomalous cases of, 204 

and debility, 206 

and deferential ampullations, 197 

diagnosis of, 206 

and ejaculatory ducts, 198 

and lack of nerve force, 206 

and mutilating meatotomy, 205 

partial, 205 

prognosis of, 207 

and seminal vesicles, 197 

and stricture of urethra, 201 

treatment of, 207 

and urethral calculi, 201 
Atonic impotence, causes of, 99 
forms of, 98 
treatment of, 102 
Atresia of cervix uteri and sterility, 
348 

of uterus and sterility, 348 

of vagina and sterility, 349 
Atrophv, progressive, of vulva, 422 

of testes, 184 

and varicocele, 279 
Azoospermatism, 155 

and hematocele, 174 

and hydrocele, 173 



Azoospermatism and morbid condi- 
tions, 193 
and tuberculosis of prostate, 181 
of seminal vesicles, 183 
of testes, 175 



BEARD on sexual erethism, 300 
Bennett's operation for varico 
cele, 284 
Bifid penis, 113 
Bottcher's sperma crystals, 72 
Bougie a boule, 221 

olivary, 224 
Brain disease and masturbation, 287 
Bu-b, sinus of, 33 
Bulbous urethra, 28 

expansion of, 32 
stenosis of, treatment of, 222 
stricture of, treatment of, 
222 
urethritis, chronic, 208 
anatomy of, 209 
symptoms of, 210 
and impotence, 208 
symptomatic, 90 



CALCULI, preputial, and organic 
impotence, 136 
and prostate, 253 
Cancer of penis and organic impo- 
tence, 130 
treatment of, 132 
Caput gallinaginis, 40 
Caruncles, urethral, 374 
Catarrhal inflammation of prostate, 
237 
prostatitis in older subjects, 245 
in young subjects, 239 
Catheter, reflux, 217 
soft-rubber, 218 
Cerebral congestion and masturba- 
tion, 291 



428 



INDEX. 



Cerebrospinal disease and priapism, 

335 
Cervix, ulceration of, and sterility, 
348 
uteri, atresia of, and sterility, 348 
hypertrophy of, and steril- 
ity, 349 
Chancre of penis and organic impo 

tence, 108 
Chancroidal distention of vulva, 388 
ulceration of penis and organic 
impotence, 119 
Chancroids of vulva, chronic, treat- 
ment of, 393 
in old syphilitics, 398 
Chlorosis and sterility in female, 347 
Clitoridean masturbation in female, 

358 
Clitoridectomy, 365 
Clitoris, abnormal situation of, and 
masturbation in female, 361 
adhesion of, and masturbation 
in female, 361 
treatment of, 364 
smegma under, and masturbation 
in female, 361 
Coitus above and sexual excesses, 298 
cohesion in, 353 
excessive, 187 
interruptus, 324 
reservatus, 324 
Compressor urethrse muscle, 31 

spasm of, 32 
Condylomata of vulva, 394 
Conjugal onanism, 324 

Eulenberg on, 329 

and irritability of heart in 

women, 329 
mechanism of, 329 
motives of, 324 
neuralgia of testis in, 328 
Peyer on, 328 

symptoms of, in females, 
329 
in males, 327 
treatment of, 332 
Cord, torsion of, and strangulation 

of testis, 172 
Corpora cavernosa, fibroid sclerosis 
of, etiology of, 
144 
and organic impo- 
tence, 139 
pathology of, 145 
prognosis of, 145 
treatment of, 145 



Corpora cavernosa, structure of, 20 
sympathetic nerves of. 23 
syphilis of, diagnosis of, 147 
and organic impotence, 

146 
prognosis of, 147 
treatment of, 148 
Corpus spongiosum, 21 
structure of, 21 
syphilis of, and organic im- 
potence, 146 
Cowper's glands, 36 

secretion of, 37 
Crista galli, 40 
Crus penis, 21 
Crypts of Morgagni, 35 
Cryptorchism and rudimentary penis, 

113 
Curves, subpubic, 34, 35 

of urethra, 34 
Cylinders, hyaline, in prostate, 252 
Cysts, ovarian, and sterility, 348 



DEBILITY and aspermatism, 206 
Deferentitis, gonorrheal, 161 
syphilitic, 166 
Diagnosis of aspermatism, 206 

of chronic posterior urethritis, 
215 
seminal vesiculitis, 273 
of new growths of vulva, 420 
of prostatorrhcea, 255 
of sexual neurasthenia, 319 
of syphilis of corpora cavernosa, 
147 
Dilatation, gradual, 223 
Ducts, ejaculatory, 52 

and aspermatism, 198 
causes of distortion of, 198 
functions of, 52 
hemorrhage around, 192 
lesions of, 198 
plugging of, 198 
secretion of, 74 
situation of, 42 
stenosis of, 199 
structure of, 51 



ECTOPIA testis, 156 
Effemi nation, 345 
Ejaculation, mechanism of, 59 
Ejaculations, bloody, 191 
in masturbation, 289 
Ejaculatory ducts, 52 



INDEX. 



429 



Ejaculatory ducts and aspermatism, 
198 
causes of destruction of, 198 
functions of, 52 
hemorrhage around, 192 
lesions of, 198 
plugging of, 198 
secretion of, 74 
situation of, 42 
stenosis of, 199 
structure of, 51 
Elephantiasis of penis and organic 
impotence, 115, 128 
treatment of, 130 
Endocervitis and sterility, 349 
Endometritis, catarrhal, and sterility, 

348 
Endoscopic tubes, 220 
Epididymis, 53 
Epididymitis, chronic, 168 
gonorrheal. 158 
syphilitic, 162 
Epispadias and organic impotence, 

112 
Erection, inhibitory nerves of, 22 
mechanism of, 56 
physiology of, 57 
Erectores penis, 53 
Erethism, sexual, 299 

and affections of deep sexual 

apparatus, 302 
Beard on, 300 
Guelliot, case of, 300 
treatment of, 302 
Erotomania, 362 

Eulenberg on conjugal onanism, 329 
External genitals, sensorium com- 
mune of, 23 



FALLOPIAN tubes, absence of, and 
sterility, 348 
dislocation of, and sterility, 
348 
Fetichism, 344 
Fibroid sclerosis of corpora cavernosa 

and organic impotence, 139 
Fibroids, uterine, and sterility in the 

female, 349 
Follicles, Littre's, 35 

anatomy of, 36 
urethral, secretion of, 35 
Fossa navicularis, 28 
Functions of ejaculatory ducts, 52 
of penis, 20 
of prostate gland, 38 



Functions of seminal vesicles, 48 
of sinus pocularis, 41 

Funiculitis gonorrheal, 161 
syphilitic, 166 



GANGRENE of penis and organic 
impotence, 108 
Genitals, external, sensorium com- 
mune of, 23 
Gland, prostate, 83 

anatomy of, 39 
function of, 38 
structure of. 38 
Glands, Cowper's, 36 

secretion of, 37 
of urethra, secretion of, 37 
Glandulce Tysonii odortferce, 25 
Glandular structure of prepuce, 25 
Glans penis, structure of, 21 
Gonorrhoea of vas deferens, 158 
Gonorrhceal congestion of prostate, 
229 
deferentitis, 161 
epididymitis, 158 
funiculitis, 161 
orchitis, 160 
Granular phosphates, 232 
Granules, seminal, 64 
Grave disease and sterility in fe- 
males, 347 
Gray on neurasthenia, 317 
Grip orchitis, 171 
Guelliot's case of sexual erethism, 300 



HEAET, irritability of, in women, 
and conjugal onanism, 329 
Hematocele and azoospermatism, 174 

treatment of, 174 
Henle's triangular ligament, 30 
Homo-sexuality, 344 
Horny growths of penis and organic 
impotence, 127 
treatment of, 127 
Hydrocele and azoospermatism, 173 
and organic impotence, 110 
treatment of, 174 
Hydro-sal pingitis and sterility, 348 
Hymen, imperforate, and sterilitv, 
349 
small, and sterility, 349 
Hypertrophic growths of vulva, 372, 

379 
Hypertrophy of cervix uteri and 
sterility, 349 



430 



INDEX. 



Hypertrophy of penis and organic 
impotence, 114 
of prostate, 260 
cause of, 260 
development of. 260 
symptoms of, 261 
treatment of, 263 
of vulva, 381 

pathology of, 386 
treatment of, 387 
Hypochondriasis and masturbation, 
294 
sexual, causes of, 312 
symptoms of, 313 
Hypospadias and organic impotence, 
111 



IMPOTENCE, atonic, causes of, 99 
1 forms of, 98 

treatment of, 102 
and bulbous urethritis, 208 
and chronic posterior urethritis, 

211 
in male, 76 

general considerations of, 76 
organic, 105 

and absence of urethra, 113 
from absence of penis, 106 
and cancer of penis, 130 
from chancre of penis, 108 
and chancroidal ulceration 

of penis, 119 
and curvature of penis, 148 
and double penis, 115 
and elephantiasis of penis, 

115, 128 
and enlargement of dorsal 

veins of penis, 117 
and epispadias, 112 
and fibroid sclerosis of cor- 
pora cavernosa, 139 
and fracture of penis, 150 
and gangrene of penis, 121 
from gangrene of penis, 108 
and horny growths of penis, 

127 
from hydrocele, 110 
and hypertrophy of penis, 

114 
and hypospadias, 111 
and indurating oedema of 

penis, 133 
and ossification of penis, 137 
from phagedena of penis, 

107 



Impotence, organic, and preputial 
calculi, 136 
and rudimentary penis, 113 
and syphilis of corpora ca- 
vernosa, 146 
of corpus spongiosum, 
146 
and torsion of penis, 113 
and traumatism of penis, 

122 
and vegetation of penis, 123 
psychical, 78 
cases of, 84 
forms of, 79 
prognosis of, 86 
treatment of, 86 
and sexual excesses, 298 
symptomatic, 88 

from bulbous urethritis, 90 
from chronic prostatitis, 93 

urethritis, 93 
from inflammation of sem- 
inal vesicles, 96 
from peripheral irritation, 

89 
from posterior urethritis, 92 
from stricture of urethra, 
91 
Infective processes and orchitis, 169 
Inflammation, catarrhal, of prostate, 
237 
of seminal vesicles and symp- 
tomatic impotence, 96 
of verumontanum, 231 
prognosis of, 235 
treatment of, 235 
Inhibitory nerves of erection, 22 
Insanity, exhibition of, and mastur- 
bation, 292 
Integument of penis, 24 
Interstitial salpingitis and sterility, 

348 _ 
Inversion of uterus and sterility, 349 
Irritation, peripheral, and symp- 
tomatic impotence, 89 
Ischio-cavernous muscles, 53 



KEMP'S rectal irrigation, 230 
Kraurosis vulvae, 422 

Baldy and Williams on,423 
course of, 423 
etiology of, 424 
pathology of, 424 
symptoms of, 423 
treatment of, 424 



INDEX. 



431 



[ ACUNA magna. 35 
Jj of Morgagui, 35 
Leukemic priapism, 339 
Levator ani, 53 
Ligament, triangular, 30 

of Henle, 30 
Lime, phosphate of, 242 
Littre's follicles, 35 

anatomy of, 36 



MALARIAL orchitis, 170 
Male, impotence in, 76 

general considerations of, 

. 76 
sterility in, 153 

urethra, structure of, 27 

Masturbation in female, 357 

and abnormal situation of 
clitoris, 361 

infants, 357 

and adhesion of clitoris, 
361 

and nervous diseases, 35S 

treatment of, 363 

vaginal, 358 
in males, ailments from, 294 

and brain diseases, 287 

from cerebral congestion, 
292 

damage by, 290 

and damaging shocks on 
nervous system, 290 

effects of, 287 

on genital organs, 290 
on sexual organs, 293 

ejaculations in, 289 

extent of, 287 

and hypochondriasis, 294 

and ill-health, 294 

from insanity, exhibition, 
292 

by means of mechanical im- 
plements, 290 

morbid process in deep 
seminal parts, 290 

and neurasthenia, 294 

and neuropathic antece- 
dents, 292 

periodical, 292 

and prostate, 289 

structural changes induced 
by, 290 

symptoms of, 293 

treatment of, 295 
and sexual perverts, 345 



Masturbation and varicocele, 280 

in young children, 287 
causes of, 287 
Meatotomy, mutilating, and asper- 

matism, 205 
Meatus urinarius, 21 

structure of, 27 
Mediastinum testis, 53 
Mechanism of ejaculation, 59 

of erection, 56 

of seminal vesicles, 49 
Membranous urethra, 30 
Mesochism, 343 
Microscopy of semen, 65 
Mobility of urethra, 34 
Morgagni, crypts of, 35 

lacunae of, 35 
Mump orchitis, 169 
Muscle, compressor urethrse, 31 
spasm of, 32 

ischio-cavernous, 53 

of prostatic urethra, 42 

of sexual apparatus, 52 



Vf AVICULAR urethra, 28 
-^ Neoplasms of vulva, 408 

pathology of, 417 
Nerve force, lack of, and asperma- 

tism, 206 
Nerves, inhibitory of erection, 22 
of penis, 22 
of prostate, 43 

sympathetic, of corpora caver- 
nosa, 23 
Nervi erigentes, 22 
Nervous disease and masturbation in 
female, 358 
system and masturbation, 290 
Neuralgia of testes and conjugal 

onanism, 328 
Neurasthenia and masturbation, 
294 g 
causes of, 314 
diagnosis of, 319 
etiology of, 314 
pathology of, 315 
prognosis of, 319 
sexual, 313 

and sterility in female, 347 
symptoms of, 316 

local, 318 
treatment of, 320 
Nocturnal pollutions, 305 
Nympha?, degeneration of, 422 
Nymphomania, 362 



432 



INDEX. 



ABESITY and sterility in female, 
V' 347 

(Edenia, indurating, of penis, and or- 
ganic impotence, 133 
of vulva, 395 
Olivary bougie, 224 
Onanism, cases of, 324 
conjugal, 324 
Eulenberg on, 329 
and irritability of heart in women, 

329 
mechanism of, 329 
motives of, 324 
neuralgia of testes in, 328 
Peyer on, 328 
symptoms of, in female, 329 

in male, 327 
treatment of, 332 
Oophoritis, chronic, and sterility, 

348 
Orchitis, chronic, 168 
gonorrhoea^ 160 
grip, 171 

and infective processes, 169 
malarial, 170 
mump, 169 

from muscular effort, 171 
scarlatina, 170 
syphilitic, 163 
tonsillar, 170 
variolous, 170 
Organic impotence, 105 

from absence of penis, 106 

of urethra, 113 
and cancer of penis, 130 
from chancre of penis, 108 
and chancroidal ulceration 

of penis, 119 
and curvature of penis, 148 
and double penis, 115 
and elephantiasis of penis, 

115, 128 
and enlargement of dorsal 

veins of penis, 117 
and epispadias, 112 
and fibroid sclerosis of cor- 
pora cavernosa, 139 
and fracture of penis, 150 
and gangrene of penis, 121 
from gangrene of penis, 108 
and horny growth of penis, 

127 
from hydrocele, 110 
and hypertrophy of penis, 

114 
and hypospadias, 111 



Organic impotence and indurating 
oedema of penis, 133 
and ossification of penis, 137 
from phagedena of penis, 

107 
and preputial calculi, 136 
and rudimentary penis, 1]3 
and syphilis of corpora cav- 
ernosa, 146 
of corpus spongiosum, 
146 
and torsion of penis, 113 
and traumatism of penis, 122 
and vegetations of penis, 123 
Ossification of penis and organic im- 
potence, 137 
treatment of, 139 
Ovarian cysts and sterility, 348 

neoplasms and sterility, 348 
Ovaries, absence of, and sterility, 348 
Oxalate of lime, 240 



PATHOLOGY of chronic posterior 
urethritis, 216 
seminal vesiculitis, 274 
of fibroid sclerosis of corpora 

cavernosa, 145 
of hypertrophy of vulva, 386 
of kraurosis vulvae, 424 
of neoplasms of vulva, 417 
of sexual neurasthenia, 315 
Parturition and sterility, 347 
Penile urethra, 29 

length of, 33 
Penis, absence of, 106 

from chancre, 108 
congenital, 106 
from gangrene, 108 
and organic impotence, 106 
from syphilitic phagedena, 
107 
arteries of, 21 
bifid, 113 

cancer of, and organic impotence, 
130 
treatment of, 132 
captivus, 353 
chancroidal ulceration of, and 

organic impotence, 119 
curvature of, and organic impo- 
tence, 148 
double, and organic impotence, 

115 
elephantiasis of, and organic im- 
potence, 115, 128 



INDEX. 



433 



Penie, elephantiasis of, treatment of, 
130 
enlargement of dorsal veins of, 

and organic impotence, 117 
fracture of, and organic impo- 
tence, 150 
treatment of, 150 
functions of, 20 

gangrene of, and organic impo- 
tence, 121 
horny growths of, and organic 
impotence, 127 
treatment of, 127 
hypertrophy of, and organic im- 
potence, 114 
indurating oedema of, and organic 

impotence, 133 
integument of, 24 
nerves of, 22 

ossification of, and organic im- 
potence, 137 
treatment of, 139 
phagedena of, and organic im- 
potence, 107 
rudimentary, and cryptorchism , 
113 
and organic impotence, 113 
structure of, 20, 24 . 
torsion of, and organic impo- 
tence, 113 
traumatism of, and organic im- 
potence, 122 
vegetations of, and organic im- 
potence, 123 
treatment of, 125 
veins of, 22 
Perineum, ruptured, and sterility, 

349 
Perioophoritis and sterility, 347 
Peripheral irritation and symptom- 
atic impotence, 89 
Perversion, sexual, 343 
Peyer on conjugal onanism, 328 
Phagedena of penis and organic im- 
potence, 107 
Phosphate of lime, 242 
Phosphates, granular, 232 

triple, 242 
Physiology of erection, 57 
Pollutions, nocturnal, 305 
Potentia cceundi, 155 

generandi, 155 
Prepuce, glandular, 25 
structure of, 24 
Tyson's glands of, 25 

structure of, 26 



Preputial calculi and organic impo- 
tence, 136 
Priapism, 333 

and alcoholic excesses, 336 
and cerebro-spinal disease and 

sexual excesses, 335 
etiology of, 339 
forms of, 333 
and leukaemia, 339 
prognosis of, 341 
after spinal injury, 334 
symptoms of, 337 
treatment of, 341 
Prognosis of aspermatism, 207 

of chronic seminal vesiculitis, 

275 
of fibroid sclerosis of corpora 

cavernosa, 145 
of inflammation of verumon- 

tanum, 235 
of new growth of vulva, 420 
of priapism, 341 
of prostatorrhoea, 256 
of psychical impotence, 86 
of sexual neurasthenia, 319 
of syphilis of corpora cavernosa, 
147 
Prolapse of uterus and sterility, 349 

of vagina and sterility, 349 
Prostate, amyloid bodies in, 252 
arteries of, 43 
and calculi, 253 
catarrhal inflammation of, 237 
concretions of, 252 
congestion of, treatment of, '230 
gland, 38 

anatomy of, 39 
functions of, 38 
structure of, 38 
gonorrhoeal congestion of, 229 
hyaline cylinders in, 252 
hypertrophy of, 260 
course of, 260 
development of, 260 
symptoms of, 261 
treatment of, 263 
massage of, 258 
nerves of, 43 
secretions of, 71 
senile changes in, 246 
tuberculosis of, and azoosperma- 
tism, 181 
treatment of, 182 
veins of, 43 
Prostatic secretion, influence of, 189 
tubules, 42 



28 



434 



INDEX. 



Prostatic tubules, seat of, 42 
urethra, 28, 40 
muscles of, 42 
Prostatitis, catarrhal, in older sub- 
jects, 245 
in young subjects, 239 
chronic, secretions of, 249 

and symptomatic impotence, 

93 
treatment of, 257 
Prostatorrhcea, 253 
diagnosis of, 255 
prognosis of, 256 
treatment of, 257 
Prostitution and sterility in females, 

347 
Psychical impotence, 78 
cases of, 84 
forms of, 79 
prognosis of, 86 
treatment of, 86 
Psychrophor, 235 

Pus admixture and spermatozoa, 190 
Pyosalpingitis and sterility, 348 

RECTAL irrigation, Kemp's, 230 
Reflux catheter, 217 
Retroversion and sterility, 349 
Rudimentary penis and cryptor- 
chism, 113 
and organic impotence, 113 
uterus and sterility, 349 

O ADISM, 343 

O Salpingitis and sterility, 348 
Sarcocele syphilitic, 164 
Scarlatina orchitis, 170 
Secretions of acute seminal vesicu- 
litis, 268 
of chronic prostatitis, 249 

seminal vesiculitis, 271 
colloid, 194 
of Cowper's glands, 37 
diminished quantity of, 195 
prognosis of, 195 
treatment of, 196 
of ejaculatory ducts, 74 
of glands of urethra, 37 
of inflamed deferential ampul 

lations, 271 
microscopy of. 65 
of prostate, 71 
semen, 61 

of seminal vesicles, 69 
of sinus pocularis, 74 



Secretions, structure of, 61 
of urethral follicles, 35 
watery, 194 
Seminal granules, 64 
vesicles, 43 

anatomy of, 47, 70 
and aspermatism, 197 
functions of, 48 
inflammation of, and symp- 
tomatic impotence, 96 
mechanism of, 49 
secretion of, 69 

anatomy of, 70 
structure of, 43 
tuberculosis of, and azo- 
ospermatism, 183 
treatment of, 183 
vesiculitis, acute, 264 

secretions of. 268 
symptoms of, 264 
advanced form of, 269 
chronic, 267 

diagnosis of, 274 
pathology of, 275 
prognosis of, 275 
secretions of, 271 
treatment of, 275 
Seminiferous tubules, 53, 62 
Sensorium commune of external gen- 
itals, 23 
Septum pectiniforme, 20 
Sexual apparatus, muscles of, 52 

desire, absence of, and sterility 

in female, 347 
erethism, 299 

and affections of deep sexual 

apparatus, 302 
Beard on, 300 
Guelliot's case of, 300 
treatment of, 302 
excesses, 297 

and alcoholism, 297 
and bestial practices, 298 
capacity, 297 
and coitus ab ore, 298 
and impotence, 298 
and physical decny, 299 
and priapism, 336 
treatment of, 299 
in young men, 299 
hypochondriasis, causes of, 312 

svmptoms of, 313 
lust, 343 

neurasthenia, 313 
causes of, 314 
diagnosis of, 319 



IXDEX. 



435 



Sexual neurasthenia, etiology of, 314 
pathology of, 315 
prognosis of, 319 
symptoms of, 316 

local, 318 
treatment of, 320 
organs, effects of masturbation 

on, 293 
perversion, 343 

and hair despoilers, 344 
perverts and masturbation, 345 
worry, 309 

conditions inducing, 310 
instances of, 310 
Sinus of bulb, 33 
pocularis, 40 

function of, 41 
secretion of, 74 
structure of, 40 
Sodomy, 345 
Sound, Beneque's, 226 
cupped, 236 
steel, 225 
Spasm of compressor urethras muscle, 

32 
Sperma crystals, 72 
Spermatic veins, excision of, in vari- 
cocele, 283 
Spermatoblasts, 53 
structure of, 62 
Spermatogenesis, 62 
Spermatorrhoea, 303 
defecation, 304 
imaginary, 306 

and urethrorrhceaexlibidine, 307 
urination, 304 
Spermatozoa, number of, 68 
and pus-admixture, 190 
structure of, 64 
Sphincter ani, 53 
Spinal injury and priapism, 334 
Spongy urethra, 28 
Stenosis, cicatricial, and sterility, 349 
Sterility in the female from absence 
of Fallopian tubes, 348 
of ovaries, 348 
of sexual desire, 347 
of uterus, 348 
of vagina, 349 
from anaemia, 347 
from anteversion, 349 
from atresia of cervix uteri, 
348 
of uterus, 348 
of vagina, 349 
from capacious vagina, 349 



Sterility in the female from catarrhal 
endometritis, 348 
from chlorosis, 347 
from chronic oophoritis, 348 
from cicatricial stenosis, 349 

of vagina, 349 
from dislocation of Fallo- 
pian tubes, 348 
from endocervitis, 349 
from fissure of uterine neck, 

349 
from grave disease, 347 
from hydrosalpingitis, 348 
from hypertrophy of cervix 

uteri, 349 
from imperforate hymen,349 
from interstitial salpingitis, 

348 
from inversion of uterus, 349 
from neurasthenia, 347 
from obesity, 347 
from ovarian neoplasms, 348 
from parturition, 347 
from peri-oophoritis, 347 
from prolapse of vagina, 349 

of uterus, 349 
from prostitution, 347 
from purulent vaginitis, 349 
from pyosalpingitis, 348 
from retroversion, 349 
from rudimentarv uterus, 

349 
from ruptured perineum, 349 
from salpingitis, 348 
from shortness of vagina, 349 
from small hymen, 349 
from syphilis, 347 
from ulceration of cervix, 

348 
from undeveloped uterus, 

349 
from uterine fibroids, 349 
subinvolution, 349 
in the male, 153 
Stricture of bulbous urethra, treat- 
ment of, 322 
of urethra and symptomatic im- 
potence, 91 
Structure of corpora cavernosa, 20 
of corpus spongiosum, 21 
of ejaculatory ducts, 51 
of glans penis, 21 
of male urethra, 27 
of meatus urinarius, 27 
of penis, 24 
of prepuce, 24 



436 



INDEX. 



Structure of prostate gland, 38 
of semen, 61 
of seminal vesicles, 43 
of sinus pocularis, 40 
of spermatoblasts, 62 
of spermatozoa, 64 
of urethra and aspermatism, 201 
of utriculus masculinus, 40 
Subpubic curve, 35 
Symptomatic impotence, 88 

from bulbous urethritis, 90 
from chronic urethritis, 93 

prostatitis, 93 
from inflammation of sem- 
inal vesicles, 96 
from peripheral irritation, 89 
from posterior urethritis, 92 
from stricture of urethra, 91 
Symptoms of chronic bulbous ure- 
thritis, 210 
posterior urethritis, 212 
of conjugal onanism in male, 
327 
in women, 329 
of hypertrophy of prostate, 261 
of kraurosis vulvas, 423 
local, of sexual neurasthenia, 318 
of masturbation, 293 
psychical, of varicocele, 282 
of priapism, 337 
of seminal vesiculitis, 264 
of sexual hypochondriasis, 313 

neurasthenia, 316 
of varicocele, 280 
Syphilis of corpora cavernosa, diag- 
v nosis of, 147 

and organic impotence, 

156 
prognosis of, 147 
treatment of, 148 
corpus spongiosum and organic 

impotence, 146 
distortion of vulva in, 399 
hereditary, of testes, 166 

treatment of, 166 
and sterility in females, 347 
treatment of, 404 
of vulva and chronic chancroids, 
398 
Syphilitic difFerentitis, 166 
epididymitis, 162 
funiculitis, 166 
orchitis, 163 
phagedena and absence of penis, 

107 
sarcocele, 164 



Syringe, author's, 220 
hand-, 217 



rFESTIS, 53 
A atrophy of, 184 

and varicocele, 279 
ectopia and azoospermatism, 156 
hereditary syphilis of, 166 
treatment of, 166 
mediastinum, 53 
neuralgia of, and conjugal onan- 
ism, 328 
strangulation of, and torsion of 

cord, 172 
tuberculosis of, 175 
treatment of, 181 
Tonsillar orchitis, 170 
Torsion of cord and strangulation of 
testis, 172 
of penis and organic impotence, 
113 
; Transversus perinei, 53 
! Traumatism of penis and organic im- 
potence, 122 
Treatment of adhesions of clitoris, 364 
of aspermatism, 207 
of atonic impotence, 102 
of cancer of penis, 132 
of chronic chancroids of vulva, 
393 
posterior urethritis, 216 
seminal vesiculitis, 275 
of condylomata of vulva, 404 
of congestion of prostate, 230 
of conjugal onanism, 332 
of elephantiasis of penis, 130 
of fibroid sclerosis of corpora 

cavernosa, 145 
of fracture of penis, 150 
of hematocele, 174 
of hereditary syphilis of testes, 

166 
of horny growths of penis, 127 
of hydrocele, 174 
of hypertrophy of prostate, 263 

of vulva, 387 
of indurating oedema of penis, 

135 
of inflammation of verumonta- 

num, 235 
of kraurosis vulvas, 424 
of masturbation, 295 

in female, 363 
of new growths of vulva, 421 
of ossification of penis, 139 



INDEX. 



437 



Treatment of priapism, 341 
of prostatorrhoea, 257 
of psychical impotence, 86 
of sexual erethism, 302 
excesses, 299 
neurasthenia, 320 
of stenosis of bulbous urethra 

222 
of stricture of bulbous urethra, 

222 
of syphilis of corpora cavernosa, 

148 
of tuberculosis of prostate, 182 
of seminal vesicles, 183 
of testis, 181 
of vulva, 407 
of vaginismus, 355 
of varicocele, 282 
of vegetations of penis, 125 
of vulva, 375 
Triangular ligament, 30 

of Henle, 30 
Tuberculosis of prostate and azo- 
bspermatism, 181 
seminal vesicles and azo- 
Sspermatism, 183 
treatment of, 183 
treatment of, 182 
testes, 175 

and azoospermatism, 175 
treatment of, 181 
of vulva, 406 

treatment of, 407 
Tubules, prostatic, 42 
seat of, 42 
seminiferous, 53, 62 
Tyson's glands, 25 



ULCERATION, chancroidal, of 
penis, and organic impotence, 
119 
of vulva, 401 
Urethra, absence of, and organic im- 
potence, 113 
anterior, 29 
bulbous, 28 

expansion of, 32 
stenosis of, treatment of, 222 
stricture of, treatment of, 
222 
course of, 29 
curves of, 34 

glands of, secretion of, 37 
membranous, 30 
mobility of, 34 



Urethra, navicular, 28 
penile, 29 

length of, 33 
prostatic, 28 

anatomy of, 40 
muscles of, 42 
spongy, 28 

stricture of, and aspermatism, 
201 
and symptomatic impotence, 
91 
Urethral calculi and aspermatism, 
201 
caruncles, 374 
follicles, secretion of, 35 
Urethritis, bulbous, and impotence, 
208 
and symptomatic impotence, 
90 
chronic bulbous, 208 

anatomy of, 209 
symptoms of, 210 
posterior, diagnosis of, 215 
and impotence, 211 
pathology of, 216 
symptoms of, 212 
treatment of, 216 
and symptomatic impotence, 
93 
posterior, and symptomatic im- 
potence, 92 
Urethrorrhcea ex libidine, 75 
Urination spermatorrhoea, 304 
Urnings, 344 

Uterine fibroids and sterility in the 
female, 349 
neck, fissure of, and sterility, 349 
subinvolution and sterility, 349 
Uterus, absence of, and sterility, 348 
atresia of, and sterility, 348 
inversion of, and sterility, 349 
. prolapse of, and sterility, 349 
rudimentary, and sterility, 349 
undeveloped, and sterility, 349 
Utriculus masculinus, 40 . 
structure of, 40 



VAGINA, absence of, and sterility, 
349 
atresia of, and sterility, 349 
capacious, and sterility, 439 
prolapse of, and sterility, 349 
shortness of, and sterility, 349 
spasm of, 353 
Vaginal masturbation in female, 358 



438 



INDEX. 



Vaginismus, 351 

and caruncles, 352 
and fissure of anus, 351 
forms of, 352 
mild, 351 
severe, 352 
Marion Sims on, 352 
superior, 356 
treatment of, 355 
Vaginitis, purulent, and sterility, 349 
Varicocele, 278 

appearance of, 278 

and atrophy of testis, 279 

Bennett's operation in, 284 

cause of, 278 

and masturbation, 280 

symptoms of, 281 
open operation in, 283 
subcutaneous ligation in, 285 
symptoms of, 280 

psychical, 282 
treatment of, 282 

by excision of spermatic 
veins, 283 
Variola orchitis, 170 
Vas deferens, 53 

gonorrhoea of, 158 
Vasa deferentia, ampullation of, 50 
Vegetations of penis and organic im- 
potence, 123 
treatment of, 125 
Veins of penis, 22 
of prostate, 43 

spermatic, excision of, in vari- 
cocele, 283 
Verumontanum, 40 

inflammation of, 231 
prognosis of, 235 
treatment of, 235 
Vesiculitis, seminal, 264 

advanced form of, 239 
acute, 264 

symptoms of, 264 
£ secretions of, 268 



Vesiculitis, seminal, chronic, 268 
diagnosis of, 274 
pathology of, 275 
prognosis of, 275 
secretions of, 271 
treatment of, 275 
Viraginity, 345 

Vitriol-throwers and sadism, 343 
Vulva, chancroids of, in old syphi- 
litica, 398 
chronic, treatment of, 393 
condylomata of, S94 
destructive ulcerations of, 401 
distention of, from chancroids, 

388 
distortion of, in syphilis, 399 
hypertrophic growths of, 372 
hypertrophy of, 366, 381 
pathology of, 386 
treatment of, 387 
indurating oedema of, 395 
neoplasms of, 408 

pathology of, 417 
new growths of, diagnosis of, 420 
etiology of, 419 
prognosis of, 420 
treatment of, 421 
progressive atrophy of, 422 
syphilis of, treatment of, 404 
tuberculosis of, 406 

treatment of, 407 
vegetations of, 369 

of exuberant growth, 370 
and hypertrophic masses, 

371 
treatment of, 375 
in young female children, 
369 



WARTY indur.-tting oedema, 
Watery semen, 194 
Webbed penis, 148 
Withdrawal, 324 



397 



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